Sides of the Same Coin: Dispelling Myths About Palliative Care in the ED

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Emergency Medicine (EM) and Hospice/Palliative Medicine (HPM) are often viewed as two medical specialties on opposite sides of the treatment spectrum. HPM focuses on relief of symptoms and stress of having a serious illness, with the goal of improving quality of life for both the patient and family. In many cases, that means avoiding aggressive medical interventions and procedures, which is the focus of EM training. Goals-of-care discussions can be time-consuming and therefore often seem incompatible with the time-pressured environment of the emergency department (ED).

However, when examined more closely, EM and HPM are actually two sides of the same coin. Both specialties care for patients and families at their most vulnerable moments with the skills to establish rapport in a very short duration of time. Both EM and HPM practitioners advocate fiercely for their patients, whether that means calling consultants multiple times in the middle of the night, or carrying out a patient’s wishes at end of life despite meeting resistance from families or even treatment teams.

Currently, there are ongoing national efforts to increase HPM presence in the ED, so you may start to see new faces from the HPM team in your ED.1 To make the introduction easier, be aware of a few common misconceptions about HPM in relation to situations that you may encounter.

 

Myth: Palliative care and hospice are the same.
Palliative care (PC) can be provided to patients with advanced disease at any time in their illness and can occur along with curative therapy. Hospice is offered to patients during the terminal phase of their disease process when the focus is solely on comfort and the treatment goal is no longer curative. Patients on hospice are expected to live 6 months or less if the disease takes its normal course. Hospice is not only for the imminently dying.

Early PC involvement has shown a decrease in hospital costs and hospital length of stay, as well as a decrease in symptom burden and increase in patient satisfaction.2,3 If PC is involved earlier in the disease course, they can assist with advanced care planning by completing living wills, which document patient wishes if in a terminal state.  These advanced care documents may relieve health care surrogates from the burden of decision making during moment of crisis in the future and help direct goals of care discussions.

Furthermore, patients who are enrolled in hospice or palliative care services have fewer encounters in the ED and are much less likely to visit during the last month of life.4 If a patient does present to the ED with uncontrollable symptoms, HPM can provide recommendations for relief. For patients who have chosen comfort but are in the later stages of dying, HPM can help with initiating hospice services in the appropriate location.

 

Myth: Morphine hastens death.
Opiates are the drugs of choice for dyspnea and pain at the end of life. Many physicians fear that administering an opiate will cause respiratory depression to the point of hastening or even causing death. The initial dose of morphine used at end of life in opiate-naïve patients is lower than what is typically used in the ED for acute pain. HPM guidelines recommend initiating opiates at low doses (2mg morphine IV or 10mg morphine PO) and titrating up based on symptoms.5 With opiate administration, the patient first experiences pain relief. As doses escalate, the patient will then experience sedation before experiencing clinically significant respiratory depression.6 Multiple studies have shown that opiates do not impact survival time in terminally ill patients.7,8 Furthermore, a patient in distress will have increased metabolic demand from muscle use, increased temperature, and tachycardia from pain and agitation. Controlling distressing symptoms leads to decreased metabolic demand and may even prolong survival.

 

Myth: Choosing comfort care means giving up conventional medical care.
Patients who choose hospice still require aggressive medical care even if the focus is on comfort. For example, hospice can accommodate patients on non-invasive positive pressure ventilation (NIPPV) both chronically and acutely at end of life for dyspnea. Studies have shown that NIPPV show similar success in both comatose and non-comatose patients, suggesting that a trial is justified to determine if hypercarbic encephalopathy may be reversible.9 If the tight mask is bothersome to the patient, then it should be removed; dyspnea can then be managed with medications.

Hospice will also support the use of antibiotics for treatment of various infections if it is felt that this will provide comfort to the patient and affect survival. Common infections such as urinary tract infections or cellulitis can cause pain and delirium that can be reversed with treatment.

Although case dependent, hospice may also support other “aggressive” therapies such as hemodialysis, milrinone infusions, radiation, paracentesis, thoracentesis, and artificial nutrition.

 

Myth: Terminal extubation can be left to ancillary staff if a morphine drip is ordered.
Withdrawal of life-sustaining treatments, such as terminal extubation, requires constant reassessment and titration of medications. Like many critical patients, frequent boluses of medication may be needed and infusions initiated. Morphine infusions take 8-10 hours before reaching the effective hourly dose and are too slow to have effect in the ED. Terminal extubation should be treated like an intubation, with a physician leading the procedure and deciding peri-procedural medications. This concept is even more important to recognize as the leader of the medical team in the ED, where withdrawal of life sustaining treatment is not typically performed. Terminal extubation is a procedure that should not be left to ancillary staff alone as studies have shown discomfort and knowledge gaps in caring for the dying in the ED.10,11

Although HPM is a relatively young specialty, their services continue to grow, especially in the ED.12 At times, HPM involvement meets resistance because of misconceptions about their practice and recommendations. I hope to have dispelled some common myths in hopes of increasing the understanding and collaboration between EM and HPM.  They are more alike than you think!

 

References
1. Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency settingAcad Emerg Med. 2011;18(6):e70-e76.
2. Wachterman M, et al. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.
3. Kavalieratos D, Corbelli J, Zhang D, et al.  Association between palliative care and patient and caregiver outcomesJAMA. 2016;316(20):2104-2114.
4. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die thereHealth Aff (Millwood). 2012;31(6):1277-1285.
5. Weissman, DE.  Fast Facts and Concepts #27 Dyspnea at End of Life.
6. Fohr SA.  The double effect of pain medication: separating myth from realityJ Palliat Med. 1998;1(4):315-328.
7. Morita T, Tsunoda J, Inoue S, Chihara S. Effects of high dose opioids and sedatives on survival in terminally ill cancer patients. J Pain Symptom Manage. 2001;21(4):282-289.
8. Sykes NP. Morphine kills the pain, not the patient. Lancet. 2007;369(9570):1325-6.
9. Tucker R, Nichols A.  UNIPAC 4 Managing nonpain symptoms.  4th ed. Grandview, IL: American Academy of Hospice and Palliative Medicne.  Dypsnea 7-19.
10. Smith AK et al.  Am I doing the right thing?  Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009;54(1): 86-93.
11. Bailey C, Murphy R, Porock D.  Trajectories of end-of-life-care in the emergency department. Ann Emerg Med. 2011;57(4):362-9.
12. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS.  The growth of palliative care in US hospitals. J Palliat Med. 2016;19(1):8-15.

Allison Chan, DO

Allison Chan, DO

Allison Chan is an attending emergency physician at Albert Einstein Medical Center and a Hospice and Palliative Medicine Fellow at Drexel University College of Medicine.
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