According to the Centers for Disease Control and Prevention, approximately 317,000 persons died in emergency departments in the United States in 2003.¹ Because the emergency department is a fast-paced and frequently high-stress, high-anxiety department, end-of-life issues are often given a lower priority. Clinical personnel may make decisions regarding patient care with suboptimal levels of information.²^–⁴ Relationships among personnel, patients, and families are limited during a time of crisis.^5,⁶ Additionally, the emergency department is usually a place of transition where patients receive stabilizing treatment and then are either transferred out or discharged. Patients usually do not remain in the emergency department for the duration of their hospital stay.⁷

The United States is a rescue-oriented culture.⁷ Cardiopulmonary resuscitation and other advanced life support measures are routinely employed in end-of-life scenarios. However, some patients do not require or want basic or advanced life support measures performed, and they may request only care-and-comfort measures at the end of their life.⁷ It is important to recognize that some patients have a poor prognosis, and although staff members have many interventions available (e.g., intubation equipment, chest compressions), these interventions are not appropriate for all patients at or near the end of life. Careful exploration with patients and families regarding their life goals and expectations for care can help determine what interventions are appropriate.⁸ For example, patients in severe respiratory distress may be brought to the emergency department by ambulance not necessarily for mechanical ventilation but because it became frightening for the family to have the patient die at home.

The interval referred to as the “end of life” is not well defined and is used inconsistently,⁹ but the term frequently applies to any interval when a patient is approaching the finality of cardiopulmonary or brain death. Emergency department staff members have a pivotal role in providing care that may be most beneficial to the patient and family. Planning that care requires engagement with the patient and family in order to explore goals and to determine which interventions are and are not appropriate. It is also important to determine, from the patient if possible, who should receive information and who should be allowed in the treatment area at this end stage.¹⁰

Emergency nurses encounter death frequently in their clinical practice, and caring for dying patients may become routine,¹¹ sometimes leading nurses to become desensitized to the suffering around them.⁶ Conversely, patients and families are often unfamiliar with death and dying. They come to the emergency department with unexpected injuries or illnesses, with chronic disease exacerbations, or with terminal illnesses seeking symptom management and lifesaving or life-prolonging treatment.⁷ Patients and families are often in crisis and seek help and answers from emergency personnel.⁶

There are seven trajectories of approaching death in the emergency department: (1) dead on arrival; (2) resuscitation in the field, resuscitative efforts in the emergency department, died in the emergency department; (3) resuscitation in the field, resuscitative efforts in the emergency department, resuscitated, and admitted to the hospital; (4) terminally ill, coming to the emergency department; (5) frail, hovering near death; (6) arriving at the emergency department alive and then suffering cardiac arrest or sudden death in the emergency department; and (7) potentially preventable death by acts of omission or commission.¹² Although emergency health care providers are masters at resuscitation, there are dying trajectories that require care interventions other than resuscitative measures. Some dying trajectories benefit from aggressive symptom management and humanistic care, whereas others call for more aggressive interventions.

Recognition of poor prognoses and framing beneficial interventions with the patient and family will help determine the plan of care. Although resuscitative measures are the standard of care in the emergency department, they may not be appropriate for all patients near the end of life. Fear of liability may be a concern of emergency personnel.^7,⁸ However, expanding the definition of “success” from the traditional concept of resuscitation to include aggressive palliative care management can ease emergency personnel’s feelings of abandoning the patient.⁸

II. PALLIATIVE CARE SYMPTOM MANAGEMENT

Palliative care is patient and family centered and multidisciplinary, and it includes symptom management, emotional/psychological care, social care, spiritual/existential care, advanced care planning, and bereavement care for the survivors.¹³^–¹⁵ In end-stage disease, treatment to relieve symptoms may be more appropriate than treatment of the underlying cause, such as infection or tumor progression. The patient must be assessed and reassessed for the presence, improvement, or reduction of symptoms before and after any intervention. Many interventions may be seen as palliative as well as therapeutic.

In patients who are near the end of life, careful consideration should be made when ordering diagnostic tests. Each test ordered should help determine an intervention. However, if the results will not change the management of the patient’s condition, the test should be questioned for its appropriateness.¹⁶

A. Advanced Preparation before Deciding on a Plan of Care ¹⁷

1. Identify the diagnosis and the prognosis

2. Determine what the patient or surrogate already knows

3. Ask whether the patient has an advance directive. If it is not readily available, ask the surrogate decision-maker what the advance directive states, and request a written copy

as soon as possible. Document in the medical record what the surrogate decision-maker states is in the advance directive

4. Seek assistance from other members of the health care team (e.g., social worker, chaplain, patient care advocate) or ask the patient or family whether they want help in contacting someone to be with them in the emergency department

5. Establish a therapeutic milieu¹⁷

a. Identify a private and quiet place in the emergency department where all family members and significant others can be seen and heard

b. Minimize interruptions

6. Seek patient and surrogate knowledge about diagnosis and prognosis¹⁷

a. Correct inaccuracies and misconceptions

b. Provide additional information

c. Communicate effectively¹⁷

1) Avoid jargon, slang, and acronyms

2) Assess whether statements have shared definitions. For example, the question “Do you want us to do ‘everything’ for your loved one?” may have a different meaning to each person

3) Demonstrate empathy

4) Be honest and direct

5) Patients and families may not be able to understand fully what is trying to be communicated to them. It is possible and permissible to help ground the family by telling them what could be done in this situation. One approach can be, “I understand that this is a very difficult time and we are providing you with a lot of information. May I tell you what I would do if this was my loved one?” If the answer is yes, then proceed. If the answer is no, then tell them that you will be available to give more information and help initiate the plan of care based on their decision

7. Make a palliative care treatment recommendation¹⁷

a. Provide rationale for recommendations

b. Answer all questions

c. Explore the possibility of a “do not resuscitate (DNR),” “do not attempt resuscitation (DNAR),” or “allow natural death (AND)” order that will avoid nonbeneficial heroic interventions such as chest compressions, defibrillation, intubation/mechanical ventilation, and/or vasopressors

8. Seek patient or surrogate agreement with recommendations¹⁷

B. Common Symptoms (Table 6-1)

1. Pain (see Chapter 9)

a. Pain and discomfort are common in patients near the end of their life

b. Inadequate pain relief

1) Hastens death

2) Increases physiologic stress

3) Potentially diminishes immunocompetency

4) Decreases mobility

5) Worsens risk of developing pneumonia and thromboembolism

6) Increases work of breathing and myocardial oxygen requirements

7) Impairs the individual’s quality of life

8) Relief of pain at the end of life may allow the patient to “let go”

c. Pain versus suffering at the end of life

1) Existential distress, fear of the dying process, and grief may alter expressions of pain

2) Pain in the terminally ill is complex and includes dimensions of psychological, social, and spiritual distress along with physical pain

3) Management of pain at the end of life must be based on an interdisciplinary approach

d. Nonpharmacologic interventions

1) Warm packs

2) Cold packs

3) Distraction/music therapy

4) Massage

5) Radiation therapy

e. Pharmacologic interventions

1) Narcotics

2) Non-narcotic analgesics

3) Acetaminophen

4) Nonsteroidal anti-inflammatory drugs (NSAIDs)

5) Adjuvant agents

a) Tricyclic antidepressants

b) Anticonvulsants

c) Local anesthetics

d) Corticosteroids

e) Baclofen (Lioresal)

f) Bisphosphonate medications (e.g., alendronate [Fosamax])

2. Dyspnea¹⁶

Table 6-1 COMMON SYMPTOMS AT THE END OF LIFE

Body System	Symptoms
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, B. R. (1998). HOPE: Home Care Outreach for Palliative Care Education Project. Duarte, CA: City of Hope.

Dyspnea is defined as distressing shortness of breath and is frequently called breathlessness. The experience of dyspnea can be very frightening. Diseases most commonly associated with this symptom include lung disease, heart disease, stroke, dementia, end-stage renal disease, and metastatic cancer.

a. Planning and implementation/interventions

1) Determine priorities of care

2) Provide supplemental oxygen as indicated

a) Oxygen use in nonhypoxemic patients may have limited benefit. A trial of oxygen should always be considered.

3) Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications as needed

a) Blood transfusions to increase oxygenation in the anemic patient

4) Prepare for/assist with medical interventions

a) Institute cardiac and pulse oximetry monitoring as indicated

b) Thoracentesis to promote better lung inflation by removing fluid from the pleural space

c) Stent placement to open an occluded airway

d) Paracentesis, when dyspnea is secondary to ascites, may improve ability to breathe

e) Nonpharmacologic treatment techniques

(1) Counseling may include the use of cognitive-behavioral, interpersonal, and complementary strategies

(2) Pursed-lip breathing slows respiratory rate and decreases small airway collapse

(3) Energy conservation techniques can save energy, reduce fatigue, and allow the patient to maintain control of lifestyle changes

(4) Fans, open windows, and air conditioners that circulate air, especially across a person’s cheek (not directly into the nasal/oral mucosa), can reduce dyspnea

(5) Elevation of the head of the bed and the ability of the patient to sit in a forward and upright position reduce choking sensations and promote expansion of the lungs. Placing the patients’ arms on pillows may promote air exchange

(6) Spiritual support can promote comfort and relaxation

(7) Education of patient and family reduces anxiety

(8) Music can promote relaxation and distraction

(9) Calm room environment by reducing stimuli and encouraging a smoke- and allergen-free atmosphere

5) Administer pharmacologic therapy as ordered (Table 6-2)

3. Cough¹⁶

Table 6-2 PHARMACOLOGIC TREATMENT FOR DYSPNEA

Thirty-nine to 80% of palliative care patients will experience cough-related problems. Cough, like dyspnea, can be very frustrating and debilitating for the patient and can cause pain, fatigue, vomiting, and insomnia. An ongoing cough is also a constant reminder of the evolving disease process. Cough is frequently present in advanced diseases such as bronchitis, heart failure, acquired immunodeficiency syndrome (AIDS), and various cancers; however, patients with lung cancer most commonly experience this symptom.

a. Planning and implementation/interventions

1) Determine priorities of care

2) Provide supplemental oxygen as indicated

a) Oxygen use in nonhypoxemic patients may have limited benefit. A trial of oxygen should always be considered

4) Administer pharmacologic therapy as ordered (Table 6-3)

4. Nausea/Vomiting¹⁶

Table 6-3 PHARMACOLOGIC TREATMENT FOR COUGH

The incidence of nausea is quite common in advanced disease; it occurs in up to 60% of terminally ill patients.¹⁸ Vomiting occurs in approximately 30% of patients, but unfortunately, this symptom has not been well researched in patients with advanced disease. The pathophysiology of nausea and vomiting is extremely complex, requiring careful assessment of the cause, which should lead to an appropriate treatment. Nausea and vomiting can be acute, anticipatory, or delayed.

a. Planning and implementation/interventions

1) Determine priorities of care

2) Provide supplemental oxygen as indicated

3) Establish IV access for administration of crystalloid fluids/medications as needed

a) Intravenous hydration for severe nausea/vomiting needs to be carefully considered. Total parental nutrition (TPN) and peripheral nutrition have very limited roles in palliative care. Some may argue that they have no role in end-stage disease

5) Administer pharmacologic therapy as ordered

a) Anticholinergics (e.g., hyoscine hydrobromide [scopolamine]) may be helpful in treating motion sickness, intractable vomiting, or small bowel obstruction

b) Antihistamines are commonly used in intestinal obstruction, increased intracranial pressure, or peritoneal irritation, and when vestibular causes exist (e.g., meclizine [Antivert] or cyclizine [Marezine])

c) Octreotide (Sandostatin) may be administered for unresectable obstruction

d) Phenothiazines (e.g., prochlorperazine [Compazine]) used for general nausea and vomiting are not highly recommended for routine use in palliative care

e) Steroids (e.g., dexamethasone [Decadron]), administered alone or with other agents for nausea and vomiting, are appropriate for cytotoxic-induced emesis

f) Prokinetic agents (e.g., metoclopramide [Reglan]) can treat gastric stasis or ileus

g) Antibiotics can decrease the impact of infectious processes

h) Antifungals (e.g., nystatin) can decrease the impact of fungal infections such as candidiasis

i) Butyrophenones (e.g., haloperidol [Haldol]) are used to treat nausea that is induced chemically, mechanically, or by opioids

j) Cannabinoids are a second-line antiemetic and typically more effective in young adults

k) Benzodiazepines (e.g., lorazepam [Ativan]) are most effective in treating nausea exacerbated by anxiety

l) Serotonin receptor antagonists are used for postoperative nausea and vomiting and chemotherapy-related emesis. These include ondansetron hydrochloride (Zofran) and granisetron hydrochloride (Kytril)

5. Diarrhea¹⁶

Diarrhea is the frequent passage of loose, nonformed stool resulting in three or more bowel movements in 1 day.¹⁹ Although much less common than constipation in the palliative care setting, diarrhea remains a common symptom. It may be especially problematic in patients with human immunodeficiency virus (HIV) infection. It can dramatically affect a person’s quality of life.¹⁹ Continuous diarrhea produces fatigue, electrolyte abnormalities, and depression and may cause a person to become homebound. Ongoing diarrhea can exhaust both patients and family. This situation can be embarrassing and time consuming and can lead to problems such as skin breakdown and dehydration.