CHAPTER 15. Palliative and End-of-Life Care in the Emergency Department
Garrett K. Chan
OVERVIEW OF PALLIATIVE AND END-OF-LIFE CARE
Palliative care is a comprehensive and specialized way to approach patients and families who face life-threatening or severe advanced illness and focuses on alleviating physical, psychologic, emotional, and spiritual suffering and promoting quality of life. 8 Palliative care emphasizes communication, advanced care planning, and symptom management using a multidisciplinary approach. 16. and 23. Multidisciplinary palliative care teams include professionals from nursing, medicine, chaplaincy, social services, and psychology and lay volunteers. Palliative care can coexist with disease-modifying interventions and starts with the initial diagnosis of illness or injury continuing through the time of the patient’s death and beyond to the survivors in the form of bereavement care. Palliative care is patient and family centered and respects personal, cultural, and spiritual values, wishes, and goals of the patient and family. End of life is a phase in the palliative care trajectory that usually focuses on the care of the person who is imminently dying. Fewer life-sustaining treatments are employed or recommended during the end-of-life phase.
In the emergency department (ED), suffering and death are common. According to the Centers for Disease Control and Prevention, approximately 317,000 persons died in U.S. EDs in 2003. 20 In addition, the ED is a fast-paced, high-stress, and high-anxiety department where staff make decisions regarding patient care with suboptimal levels of information. 4 The ED is a place of transition where patients receive initial diagnostics and stabilizing treatment and then are transferred out or discharged from the ED. This may give a false impression that the sole focus of the ED is on diagnosis and initial curative treatment, when in fact palliative care is provided to patients to help relieve pain, anxiety, and other distressing symptoms and emotions of patients and families.
Many patients who come to the ED may need palliative care. Patients who present usually have a chief complaint of a symptom such as pain, dyspnea, or nausea. Common presentations of patients who need advanced palliative or end-of-life care include patients with advanced stages of illness such as congestive heart failure, chronic obstructive pulmonary disease (COPD), dementia, and severe trauma. Other patient populations that can benefit from end-of-life care are the family of a sudden infant death syndrome (SIDS) patient or the family of a woman who has miscarried.
We live in a rescue-oriented culture where cardiopulmonary resuscitation and other advanced procedures are routinely employed. However, some patients may not need these aggressive, heroic measures; rather, they may need care-and-comfort measures, especially at the end of life. It is important for the emergency nurse to recognize that some interventions they have at their disposal such as intubation and chest compressions may not be appropriate for patients near the end of life, and careful exploration regarding life goals and expectations for care will help determine what interventions may be appropriate for each situation.
Emergency nurses play a pivotal role in helping formulate an appropriate plan of care that takes into consideration the patient’s and family’s beliefs and desires while providing only those interventions that are beneficial and appropriate. The Emergency Nurses Association (ENA) has developed a position statement to help emergency nurses provide optimal end-of-life care. 10 Last, it is important to ask the patient, if possible, who is considered to be family. Determining who is considered family allows the nurse to understand who should receive information, be allowed in the treatment area, be consulted to can help make care decisions. 14
PALLIATIVE CARE PRINCIPLES IN THE EMERGENCY DEPARTMENT
There are many definitions of palliative care. However, common among the various definitions are that palliative care is multidisciplinary, patient and family centered, and includes symptom management; emotional and psychologic care; social care; spiritual/existential care; communication and advanced care planning; and bereavement care for the survivors. 11.16.22. and 27. Core palliative and end-of-life principles of symptom management, emotional, psychologic, social, and spiritual care will be covered.
Symptom Management
Commons symptoms at the end of life are listed in Box 15-1. It is important for emergency nurses to assess for these symptoms and intervene to reduce their severity. Although all of these symptoms are important, in this chapter the focus will be on the common symptoms seen in the ED such as pain, dyspnea, nausea/vomiting, and constipation. 21
Box 15-1
C ommon S ymptoms at the E nd of L ife
| Pulmonary | Dyspnea Cough Head/nasal congestion “Death rattle” Respiratory distress/respiratory depression |
| Neurologic/Functional | Pain Spinal cord compression Weakness Fatigue Immobility Insomnia Confusion/dementia/delirium Memory changes |
| Gastrointestinal | Nausea/vomiting Dysphagia Anorexia Weight loss Unpleasant taste Ascites Constipation/obstipation/bowel obstruction Diarrhea Incontinence of bowel Hiccups |
| Urinary | Incontinence of bladder Bladder spasms Changes in function or control |
| Integumentary | Decubitus Mucositis Candidiasis Pruritus Edema Hemorrhage Infection (e.g., herpes zoster) Diaphoresis |
| Psychiatric | Depression Anxiety |
| Other | Fever |
Modified from Ferrell BR: HOPE: Home Care Outreach for Palliative Care Education Project, Duarte, Calif, 1998, City of Hope.
Nurses must assess and reassess for the presence or improvement of symptoms before and after any intervention. Importantly, many interventions can be viewed as both palliative and therapeutic. For example, if a patient with end-stage congestive heart failure (CHF) comes to the ED with a chief complaint of dyspnea, the nurse may administer furosemide (Lasix) as a palliative treatment to relieve the dyspnea from pulmonary edema. Furosemide is considered more palliative than therapeutic for end-stage CHF and pulmonary edema. Another example is if a patient with end-stage cancer comes to the ED with severe fatigue and dyspnea secondary to anemia, packed red blood cell (PRBC) units may be administered in an attempt to relieve the fatigue and dyspnea. In this example the blood administration is viewed as palliative more than disease modifying because the anemia is a chronic condition that will not be reversed.
Pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. 12 This definition reflects the multidimensional aspects of pain and takes into consideration the physiologic, emotional and social effects of this symptom. Another commonly cited definition of pain is “pain is whatever the person says it is, experienced whenever they say they are experiencing it.”19 It is important to recognize that pain is a subjective symptom, and self-report is a valid measure of pain. However, in patients who are not able to communicate their pain due to an altered level of consciousness, language barriers, aphasia, or other factors, the patients are considered to be in pain until it is proven otherwise. Because families may spend a significant time with the patient and understand the baseline comfort level, the patient’s family may be able to determine if the patient is in pain. The family should be asked by the nurse if they perceive that the patient is in pain or has any other symptom.
A common issue for emergency nurses is understanding the unique characteristics and differences between acute and chronic pain. Commonly patients who have severe acute pain present with behaviors such as yelling, writhing, grimacing, and other visible signs of discomfort. However, patients who have chronic pain (i.e., pain that lasts for weeks to months beyond acute tissue injury) may lack these visible signs of discomfort, yet they experience pain nonetheless. Acute and chronic pain differ significantly, and emergency nurses should continue to believe patients who verbalize they are in pain, regardless of the outward behaviors. It is important to note that patients may be experiencing severe pain and may be able to sleep. This phenomenon can be attributed to exhaustion and is contrary to the commonly held perceptions that pain will stop sleep. Chapter 12 explains pain pathophysiology, assessment, and management in more detail.
Patients who present with adverse side effects of opioids such as oversedation and respiratory depression (respiratory rate less than 8 breaths/min) should receive very small doses of naloxone (Narcan) to reverse the side effects without reversing the analgesic effects. Abruptly reversing both the analgesic and side effects, using naloxone, may precipitate abstinence syndrome, which can cause a range of symptoms, including anxiety, myalgias, tachycardia, hypertension, pulmonary edema, and cardiopulmonary collapse. One method of administering naloxone in patients to reverse the side effects without reversing the analgesia is as follows7:
1. Stop opioid administration.
2. Dilute 0.4 mg naloxone (one ampule) with normal saline to a total volume of 10 mL (1 mL = 0.04 mg).
3. Remind the patient to breathe; though narcotized, patients report hearing concerned staff and being unable to open their eyes or respond. Reminders to “take a deep breath” are often followed.
4. Administer 1 mL intravenously (IV) (0.04 mg) every 1 minute until the patient is responsive. A typical response is noted after 2 to 4 mL with deeper breathing and greater level of arousal. Gradual naloxone administration should prevent acute opioid withdrawal.
5. If the patient does not respond to a total of 0.8 mg naloxone (2 ampules), consider other causes of sedation and respiratory depression (e.g., benzodiazepines, stroke).
6. The duration of action of naloxone is considerably shorter than the duration of action of most short-acting opioids. A repeat dose of naloxone, or even a continuous naloxone infusion, may be needed.
7. Wait until there is sustained improvement in consciousness before restarting opioids at a lower dose.
Remember, patients may have a respiratory rate of 8 breaths/min while sleeping.
Dyspnea
Dyspnea is defined as a sense of breathlessness or shortness of breath and can be extremely distressing and frightening for both the patient and those who witness it. Many diseases cause dyspnea, including lung diseases such as COPD, pneumonia, and pulmonary embolisms; heart diseases such as congestive heart failure; end-stage renal disease; anxiety; metabolic disorders; anemia; and financial, legal, family, or spiritual issues. Initial management of dyspnea is to focus on the underlying causes and intervene with any disease-modifying treatments as appropriate. However, in some cases, the underlying cause of dyspnea may not be identified. It is important to recognize that dyspnea is a subjective symptom and the treatments need to be tailored to the amount of subjective dyspnea the patient experiences. Objective data such as oxygen saturation (SaO 2) may not correlate with the amount of dyspnea a patient is experiencing.
Assessment of dyspnea can include using a numeric rating scale such as the modified Borg scale. The modified Borg scale is a scale ranging from 0 to 10 and has been validated for use in the ED (Box 15-2). Trending the modified Borg scores will let the nurse know whether the interventions are effective in treating the dyspnea.
Box 15-2
M odified B org S caleRights were not granted to include this box in electronic media. Please refer to the printed book.
| Scale | Severity |
|---|---|
| 0 | No breathlessness∗ at all |
| 0.5 | Very, very slight (just noticeable) |
| 1 | Very slight |
| 2 | Slight breathlessness |
| 3 | Moderate |
| 4 | Somewhat severe |
| 5 | Severe breathlessness |
| 6 | |
| 7 | Very severe breathlessness |
| 8 | |
| 9 | Very, very severe (almost maximum) |
| 10 | Maximum |
| ∗The term breathlessness was added for clarification of the scale. | |
From Borg G: Psychophysical bases of perceived exertion, Med Sci Sports Exerc 14(5):377, 1982.
There are three pharmacologic approaches used commonly for dyspnea: oxygen, opioids, and anxiolytics. Although opioids and anxiolytics have side effects that include possible respiratory depression and sedation, these medications can be administered with careful titration and monitoring to avoid the adverse side effects. In addition, nonpharmacologic interventions such as positioning the patient, distraction, guided imagery, and the use of a fan to move air across the face have been shown to be effective in managing dyspnea.
Nausea and Vomiting
There are many causes of nausea and vomiting, and these symptoms are frequently seen in the ED. Nausea and vomiting can be effectively managed if the correct medications are chosen based on an accurate assessment of the underlying pathophysiology.
Two organ systems are particularly important in nausea and vomiting: the brain and the gastrointestinal (GI) tract. 8 In the brain the chemoreceptor trigger zone at the base of the fourth ventricle, the cortex, and the vestibular apparatus are areas involved in stimulating nausea and vomiting. In the GI tract the gastric and small intestine linings have chemoreceptors that are responsible for nausea and vomiting.
If stimulated, the neurotransmitters serotonin, dopamine, acetylcholine, and histamine can cause nausea and vomiting. These four neurotransmitters are found in the chemoreceptor trigger zone; however, in the vestibular apparatus, acetylcholine and histamine are predominant. In the GI tract, serotonin is the major neurotransmitter responsible for nausea and vomiting. The cortex is more complex and is not associated with specific neurotransmitters. Knowing the physiology of nausea and vomiting will help the emergency nurse understand which antiemetic might be most helpful in managing the nausea and vomiting.
Dopamine-mediated nausea is the most common form of nausea. Dopamine antagonists are classified into two categories: phenothiazines and butyrophenone neuroleptics. The phenothiazines include medications such as prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), and trimethobenzamide (Tigan). The butyrophenone neuroleptics include haloperidol (Haldol) and droperidol (Inapsine). Both the phenothiazines and butyrophenone neuroleptics have the potential to cause drowsiness and extrapyramidal side effects.
Serotonin antagonists are commonly used in the ED. Often these medications are very effective, especially with chemotherapy-induced nausea, nausea from GI distension, or with nausea that is refractory to other therapies. They are expensive and should be stopped if a short trial does not control the nausea. Medications in this drug category include ondansetron (Zofran) and granisetron (Kytril).
Histamine antagonists may also be used in nausea that may be due to medications such as opioids or chemotherapeutic agents. The histamine antagonists may also have anticholinergic properties as well. Medications in this category include diphenhydramine (Benadryl), meclizine (Antivert), or hydroxyzine (Vistaril or Atarax).
Anticholinergic agents are effective if the nausea is caused by a disturbance in the vestibular apparatus. Medications in this class may be combined with other classes of antiemetics. An example of an anticholinergic medication is scopolamine.
Adjunctive agents that may also be used in combination with the above medications include dexamethasone, tetrahydrocannabinol (THC), and lorazepam (Ativan). The mechanisms of action are unclear but have been proven to be effective in clinical trials.
Constipation
Constipation can be a very painful and distressing symptom with many causes. With opioid use, many symptoms decrease with long-term use except for constipation. Therefore a bowel regimen should be in place for all patients receiving opioids. Prevention of constipation is the best strategy in managing constipation.
The most helpful class of medications for constipation is the stimulant laxatives. Stimulant laxatives increase the peristaltic activity of the GI tract. Agents in this class include prune juice, senna preparations, and bisacodyl. Osmotic laxatives draw water into the bowel lumen, thereby increasing the stool volume and the moisture content in the stool. Medications in this class include milk of magnesia, magnesium citrate, and lactulose. Detergent laxatives, also known as stool softeners, increase the water content in the stool and facilitate the dissolution of fat in water, increasing the stool volume. Medications in this class include sodium docusate and a Phospho-soda enema. Lubricant stimulants lubricate the stool and irritate the bowel, thus increasing the peristaltic activity. Glycerin suppositories and mineral oil are two examples of lubricant stimulants. Last, large-volume enemas such as warm water or soapsuds enemas may be used to distend the colon and increase peristalsis.
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