Clinical Review

Palliative Medicine in the ED

The management of patients presenting with life-limiting illnesses is a common presentation to the ED—one that requires appropriate management of both pain and nonpain symptoms.

Emergency Medicine. 2015 August;47(8):346-352 | DOI: 10.12788/emed.2015.0008

Author(s):

Marissa C. Galicia-Castillo, MD, MSED, CMD

With the high number of patients presenting to the ED with life-limiting illnesses, the emergency physician plays a key role in palliative care—especially in the management of pain and nonpain symptoms.

References

Alsirafy SA, Raheem AA, Al-Zahrani AS, et al. Emergency department visits at the end of life of patients with terminal cancer: pattern, causes, and avoidability. Am J Hosp Palliat Care. 2015:1049909115581819. [Epub ahead of print].
Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17(11):1253-1257.
Smith AK, Schonberg MA, Fisher J, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage. 2010;39(6):972-981.
Mierendorf S, Gidvani V. Palliative care in the emergency department. Perm J. 2014;18(2):77-85.
Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6): 563-568.
Counselman FL, Borenstein MA, Chisholm CD, et al; EM Model Review Task Force; American Board of Emergency Medicine. The 2013 Model of the Clinical Practice of Emergency Medicine. Acad Emerg Med. 2014;21(5):574-598.
Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94-102.
Singer AE, Meeker D, Teno JM, Lynn J, Lunney JR, Lorenz KA. Symptom trends in the last year of life from 1998 to 2010: a cohort study. Ann Intern Med. 2015;162(3):175-183.
Lindqvist O, Lundquist G, Dickman A, et al; OPCARE9. Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion. J Palliat Med. 2013;16(1):38-43.
Kandarian B, Morrison RS, Richardson LD, Ortiz J, Grudzen CR. Emergency department-initiated palliative care for advanced cancer patients: protocol for a pilot randomized controlled trial. Trials. 2014;15:251.
Campbell ML. Caring for dying patients in the intensive care unit: managing pain, dyspnea, anxiety, delirium, and death rattle. AACN Adv Crit Care. 2015;26(2):110-120.
Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med. 2011;57(3):282-290.
Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage.2009;38(3):409-417.
Wallace EM, Cooney MC, Walsh J, Conroy M, Twomey F. Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care. 2013;30(3):253-253.
Erichsén E, Milberg A, Jaarsma T, Friedrichsen MJ. Constipation in specialized palliative care: prevalence, definition, and patient-perceived symptom distress. J Palliat Med. 2015;18(7):585-592.
Candy B, Jones L, Larkin PJ, Vickerstaff V, Tookman A, Stone P. Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015;5:CD003448.
Parshall MB, Schwartzstein RM, Adams L, et al; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452.
LeGrand SB, Khawam EA, Walsh D, Rivera NI. Opioids, respiratory function, and dyspnea. Am J Hosp Palliat Care. 2003;20(1):57-61.
Meek PM, Schwartzstein R, Adams L, el al. Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society. Am J Respir Crit Care Med. 1999;159(1):321-340.
Campbell ML, Yarandi H, Dove-Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517-523.
Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31(1):58-69.
Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-259.
Cleeland CS, Bennett GJ, Dantzer R, et al. Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. Cancer. 2003;97(11):2919-2925.
Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B; Association for Palliative Medicine’s Science Committee. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med. 2002;16(5):369-374.
Mercadamte S. Death rattle: critical review and research agenda. Support Care Cancer. 2014;22(2):
571-575.
Wildiers H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage. 2002;23(4):310-317.
Wildiers H, Dhaenekint C, Demeulenaere P, et al; Flemish Federation of Palliative Care. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009;38(1):124-133.
Kehl KA. Treatment of terminal restlessness: a review of the evidence. J Pain Palliat Care Pharmacother. 2004;18(1):5-30.

Overview

Palliative medicine in the ED represents a paradigm shift for the emergency physician (EP)—from identifying and stabilizing acute medical and surgical conditions to providing symptomatic comfort care to a dying patient. When the ED became the “safety net” for patients who have serious, life-limiting illnesses,^1-3 it also became the most frequent place where such care is initially sought⁴—although not considered an ideal place to begin such care.

In one study, approximately 40% of dying patients presented to the ED during their final 2 weeks of life.⁵ With the ED becoming more recognized as a location for palliative care, the EP plays a key role in the care of these patients. The 2013 Model of the Clinical Practice of Emergency Medicine explicitly lists palliative medicine within the EP’s scope of practice.⁶ Further support for providing palliative care in emergency medicine includes the cosponsorship of Hospice and Palliative Medicine subspecialty board certification by the American Board of Emergency Medicine in 2008. Finally, palliative care medicine principles have been endorsed in the “Choosing Wisely” initiative of the American College of Emergency Physicians.

Essential Palliative Care Skills

Quest et al⁷ have identified the following 12 primary palliative care skills in which every EP should be competent:

Assessment of illness trajectory;
Determination of prognosis;
Communication of bad news;
Interpretation and formation of an advance care plan;
Allowance of family presence during resuscitation;
Symptom management (both pain and nonpain);
Withholding and withdrawal of life-sustaining treatments;
Management of imminently dying patients;
Identification and implementation of hospice and palliative care plans;
Understanding of ethical and legal issues pertinent to end-of-life care;
Display of spiritual and cultural competency; and
Management of the dying child.

Although all of the above are important skills, this paper focuses on the symptom management of pain and nonpain (skill 6) in patients presenting to the ED with a life-limiting illness. The evidence base for these treatments is limited due to the many methodological challenges faced when studying symptoms in patients who are at end of life.

Pharmacologic Management of Symptoms

Recent research has found that symptom burden is high at end of life. Despite the increase in attention to these patients and their needs, symptoms including pain, depression, and delirium have repeatedly increased between 1998 and 2010.⁸ A 2013 study recommended that a minimum of four classes of medications be considered for patients who are at end of life: opioid (for pain); benzodiazepine (for anxiety); antipsychotic (for delirium and nausea); and antimuscarinic (for excessive secretions).⁹ The role and indications for each of these drug classes will be discussed.

Palliative Care Intervention

Though EPs frequently request specialty and subspecialty consultation for ED patients, they usually do not consider a palliative care medicine consult for the dying patient. Palliative care medicine utilizes an interdisciplinary, collaborative, team-based approach to decrease the pain and suffering of patients with advanced illness.¹⁰

Benefits from early palliative care intervention in the ED include improved symptom management, improved patient and family satisfaction, improved outcomes, decreased length of stay, less use of intensive care units, and less costs.⁴

Pain Management

Pain is one of the most devastating symptoms that a patient can experience, and its management is an integral component of palliative care medicine. Initial evaluation must include appropriate assessment of the pain and its impact on a patient’s function and quality of life.

The general approach to pain management follows the World Health Organization pain ladder. For mild to moderate pain, step 1 begins with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID), with or without an adjuvant such as an antidepressant or anticonvulsant. If pain persists, step 2 involves the addition of an opioid. For moderate to severe pain, step 3 involves the addition of stronger opioids, such as hydromorphone, morphine, and oxycodone. Typically, a patient with a serious, life-limiting illness who presents to the ED for help will likely require treatment with strong opioids (step 3).

Opioids

In patients requiring step 3 management, opioids are the primary medication used to manage pain. An initial equivalent dose of morphine 5 mg intravenously (IV) is appropriate in an opioid-naïve patient. The adage of “starting low and going slow” is important to follow; however, an important corollary is “…and use enough.” If a patient’s pain is not controlled with initial dosages, additional bolus doses of 50% to 100% increments will be necessary. Because opioids do not have a ceiling effect, it is important to understand that dosages may seem very high for some patients compared to others. In this population, ensuring baseline pain control, with either an oral long-acting formulation or a continuous IV infusion, is important.¹¹

References

Alsirafy SA, Raheem AA, Al-Zahrani AS, et al. Emergency department visits at the end of life of patients with terminal cancer: pattern, causes, and avoidability. Am J Hosp Palliat Care. 2015:1049909115581819. [Epub ahead of print].
Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17(11):1253-1257.
Smith AK, Schonberg MA, Fisher J, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage. 2010;39(6):972-981.
Mierendorf S, Gidvani V. Palliative care in the emergency department. Perm J. 2014;18(2):77-85.
Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6): 563-568.
Counselman FL, Borenstein MA, Chisholm CD, et al; EM Model Review Task Force; American Board of Emergency Medicine. The 2013 Model of the Clinical Practice of Emergency Medicine. Acad Emerg Med. 2014;21(5):574-598.
Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94-102.
Singer AE, Meeker D, Teno JM, Lynn J, Lunney JR, Lorenz KA. Symptom trends in the last year of life from 1998 to 2010: a cohort study. Ann Intern Med. 2015;162(3):175-183.
Lindqvist O, Lundquist G, Dickman A, et al; OPCARE9. Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion. J Palliat Med. 2013;16(1):38-43.
Kandarian B, Morrison RS, Richardson LD, Ortiz J, Grudzen CR. Emergency department-initiated palliative care for advanced cancer patients: protocol for a pilot randomized controlled trial. Trials. 2014;15:251.
Campbell ML. Caring for dying patients in the intensive care unit: managing pain, dyspnea, anxiety, delirium, and death rattle. AACN Adv Crit Care. 2015;26(2):110-120.
Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med. 2011;57(3):282-290.
Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage.2009;38(3):409-417.
Wallace EM, Cooney MC, Walsh J, Conroy M, Twomey F. Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care. 2013;30(3):253-253.
Erichsén E, Milberg A, Jaarsma T, Friedrichsen MJ. Constipation in specialized palliative care: prevalence, definition, and patient-perceived symptom distress. J Palliat Med. 2015;18(7):585-592.
Candy B, Jones L, Larkin PJ, Vickerstaff V, Tookman A, Stone P. Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015;5:CD003448.
Parshall MB, Schwartzstein RM, Adams L, et al; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452.
LeGrand SB, Khawam EA, Walsh D, Rivera NI. Opioids, respiratory function, and dyspnea. Am J Hosp Palliat Care. 2003;20(1):57-61.
Meek PM, Schwartzstein R, Adams L, el al. Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society. Am J Respir Crit Care Med. 1999;159(1):321-340.
Campbell ML, Yarandi H, Dove-Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517-523.
Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31(1):58-69.
Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-259.
Cleeland CS, Bennett GJ, Dantzer R, et al. Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. Cancer. 2003;97(11):2919-2925.
Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B; Association for Palliative Medicine’s Science Committee. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med. 2002;16(5):369-374.
Mercadamte S. Death rattle: critical review and research agenda. Support Care Cancer. 2014;22(2):
571-575.
Wildiers H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage. 2002;23(4):310-317.
Wildiers H, Dhaenekint C, Demeulenaere P, et al; Flemish Federation of Palliative Care. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009;38(1):124-133.
Kehl KA. Treatment of terminal restlessness: a review of the evidence. J Pain Palliat Care Pharmacother. 2004;18(1):5-30.

Palliative Medicine in the ED

The management of patients presenting with life-limiting illnesses is a common presentation to the ED—one that requires appropriate management of both pain and nonpain symptoms.

References

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