Palliative medicine

Palliative Care in the ED

• palliative care team involvement early in EOL (end of life)
• can be distressing time for family/providers

Dyspnea

• not a time to reclarify goals of care
• reassurance is key to family
• O2, NIPPV
• bedside Fan
• morphine start "low and go slow", 1-2mg IVP Q10-15min until desired effect
• if opioid tolerant, in addition to standing use - 10% of 24 hour opioid regimen Q10min; or 25% of 4 hour opioid regimen Q10min

Dehydration

• anorexia does not cause distress, no evidence for IVF, TPN
• normal to decrease po intake in last weeks of life
• swabs on mouth/lips to prevent dry lips
• artificial tears for dry eyes

Delirium

• reassurance in normal part of dying process, not "going crazy at the end"
• common to see deceased relatives
• quiet, well lit room, windows preferable, familiar faces present
• Haldol 0.5-1mg IVP show to be useful, Benzo as additional adjunct

Disposition at End of Life

1. all life sustaining care desired - self explanatory
2. comfort + limited life sustaining interventions
   1. admit to ward/pcu bed with time limited trial (establish this beforehand) for abx or nippv
3. comfort only
   1. admit to hospice unit/palliative care service or manage acute sxs in ED then dc with home hospice