II. Management: Family Counseling in Dying Patient appropriate for Palliative Care

  1. Summarize evaluation and patient status
    1. Baseline status
      1. Example: Bed-ridden with Dementia
    2. Underlying condition
      1. Example: Severe Pneumonia with Hypoxia, Hypotension and unresponsive
    3. Severity of illness
      1. Example: Critically ill and will succumb without aggressive therapy
    4. Describe standard interventions
      1. Intubation, pressors via Central Line, broad spectrum antibiotics
  2. Listen to the family
    1. Listen to family concerns and their understanding of patient wishes
    2. Acknowledge how hard this must be for them
    3. Understand if other family members not present need to be involved in discussion
    4. Identify Durable Power of Attorney if one is assigned
  3. Review advanced care planning (e.g. Advanced Directive, Living Will, Medical Directive) and POLST forms with family
    1. POLST forms are legally binding directives and can be followed exactly without interpretation
    2. Advanced Directives are interpretable and should be reviewed as to what they understand patient's wishes to be
  4. Recommendations (example)
    1. Our goal is to respect your loved one's wishes
    2. She appears to be actively dying
    3. I have very aggressive, intensive measures to support her (e.g. intubation, pressors, antibiotics)
      1. Without these interventions, she will likely succumb to her illness
      2. Despite these interventions, there is still a very high likelihood of death
    4. Many families ask us to focus on comfort and decreased suffering instead of aggressive procedures at the end of life
      1. We can very effectively treat pain and suffering
      2. Our intensive measures to keep someone alive are frequenctly at odds with our comfort measures
      3. These measures include morphine and Ativan for pain and Shortness of Breathing
    5. Based on life threatening illness at the end of life, and based on my understanding of her wishes
      1. I recommend we focus on comfort measures and avoid heroic measures which may increase suffering
      2. This would allow for a natural death
  5. Discussion
    1. Decisions may not occur in the emergency department (but rather on the ward)
    2. Initial treatment trial may be compromise
    3. Non-invasive support may be used (e.g. CPAP or BIPAP instead of intubation)

III. References

  1. Orman and Abbott in Herbert (2014) EM:Rap 14(2): 11-2

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