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 EOL

1. all life sustaining care desired - self explanatory 

2. comfort + limited life sustaining interventions

- admit to ward/pcu bed with time limited trial (establish this beforehand) for abx or nippv

3. comfort only

- admit to hospice unit/palliative care service or manage acute sxs in ED then dc with home hospice