An 87 year old woman with metastatic breast cancer and severe COPD is brought by her daughter to the emergency department because of progressively worsening shortness of breath that they have been unable to manage at home. Her family has noticed a significant decline over the last month, such that she now rarely gets out of bed. She is followed by the local palliative care team and has completed paperwork to indicate that she should not want aggressive life prolonging therapy. The daughter was very anxious about coming to the emergency department, because her mother had been intubated in the past had made it clear that she would never want that again. Unfortunately, despite following the plans of her palliative physician, they were unable to control her severe dyspnea at home…
Triage disposition: In my mind, a private room is essential for any dying patient. Because these patients don’t require a monitored bed, I find they are frequently placed at the end of a hallway, far from the nursing station. Although these rooms have the benefit of being quiet, they are generally staffed by nurses with 4 or 5 other patients (at least) and aren’t in the nurse’s direct line of site. However, an acutely dying patient requires a high level of care with frequent reassessments. I think they are best cared for initially in a resuscitation room with 1:1 or 1:2 nursing care, if available.
Call for help: The end of life is a time of extreme stress for patients and their families. Social workers and chaplain services are extremely helpful. If you happen to have an on call palliative care team, they would also be invaluable.
Rapidly identify goals of care: What would the patient want done in this scenario? If the patient cannot communicate for herself, has she previously discussed her wishes with her family? What is her current level of activity at home and how much has that changed over the past month? What kind of person was she when she was healthy?
There are two broad categories of palliative patients: 1) patients whose prognosis is hours to days and whose only goal is comfort and a good death, and 2) patients whose prognosis is weeks or longer, whose priority is comfort, but who would like easily reversible causes to be treated. Testing generally should not be done for the first group, but may be appropriate for group 2.
The palliative resuscitation: Instead of rapidly and systematically diagnosing and treating pathology, the palliative resuscitation focuses on rapidly identifying and treating symptoms. The first step is to make the room as comfortable as possible. Invite family and friends to the bedside and try to find chairs for them. Turn off all monitors. Reassure everyone that you are going to do absolutely everything to ensure the patient’s comfort. Next, ask about the patient’s symptoms. Even when dyspnea is the chief complaint, pain, nausea, and anxiety may also be present. For now, we will just focus on the management of dyspnea.
Patient positioning: Allow the patient to be in whatever position she wants, but upright lungs work best. Almost all of these patients will want to be sitting up.
Oxygen: In the non-critically ill palliative patient with COPD, oxygen therapy has been shown to increase quality of life and survival. However, in trials of non-hypoxic palliative patients, oxygen is not associated with any decrease in dyspnea. It’s not clear how that translates for the patient who is acutely dyspneic in the emergency department. Unfortunately, patients find many of the devices that we use to provide oxygen uncomfortable. I routinely provide oxygen to palliative patients with dyspnea, but recognize the balance between a potential relief of hypoxia and the discomfort and noisiness of the facemask. Frequent reassessment and discontinuation of ineffective therapies is key.
High flow humidified nasal oxygen: I can definitely see a potential role for high flow nasal oxygen in this setting. These devices can provide very high flows of oxygen, but also seem to be better tolerated by patients than traditional facemasks. In fact, despite the lack of evidence, high flow nasal oxygen is currently my go to for these patients. The major downside is that use of high flow nasal oxygen mandates an ICU admission in many hospitals. That is inconsequential if the patient is going to die imminently, but could cause problems for patients requiring admission. Common sense mandates that the ICU requirement should be ignored for palliative patients – but everyone will have to have that fight individually with their administrators.
- Opioids are the key to palliating dyspnea
- The palliative population will often have renal impairment, so avoiding opioids with active metabolites is reasonable. In the emergency department, this generally means using either hydromorphone or fentanyl. (I generally opt for hydromorphone, because fentanyl is going to wear off too quickly)
- There is debate about the best route to deliver opioids. For a patient in acute distress, I think the value of rapid titration and repeat dosing through an IV outweighs the minor discomfort of placing the IV. However, oral, intranasal, and subcutaneous routes are also reasonable
- There is no single appropriate opioid dose. These patients require ‘aggressive’ therapy, in that they will have to be reassessed frequently during their first hours in the department to have their opioid titrated. Starting low and going slow is reasonable, but these patients are critically ill and require rapid reassessment.
- For example, dilaudid 0.2-0.5 mg IV q 4-5 minutes until relief, doubling the dose if not effective after the first 2 doses
- Despite many people’s fears, opioids probably don’t shorten life in palliative patients (See Portenoy 2006 and Bengoechea 2010 in the references)
Anxiolytics: If opioids aren’t working, it’s probably because you aren’t using enough opioids. However, depression and anxiety are a common component of dying, so it might be reasonable to add a small dose of benzodiazepine for some patients.
Nonpharmacologic therapies: The most important nonpharmacologic therapy is the presence of family and friends. Family presence is essential to most people’s conception of a good death. However, I will often encourage family to do more than just be present. By talking to and interacting with the patient, families often provide an important distraction from distressing symptoms.
Dyspnea is also frequently relieved by directing an electric fan towards the patient’s face, or by opening a window if that is somehow possible in your ED.
Noninvasive positive pressure ventilation: There are no studies that explore the use of NPPV for comfort care only. Its value in palliative care is hotly debated. In my mind, there are two uses of NPPV to consider: purely palliative and palliative, but possibly curative. The purely palliative approach to NPPV is easy: NPPV is offered to the patient with the sole goal of improving comfort. It is reassessed constantly in this context and if comfort is not improved, it is discontinued. The palliative but possibly curative use of NPPV is what gets people confused. End-stage COPD is a condition marked by progressive decline, but with acute exacerbations from which the patient can return close to their baseline. In the initial minutes in the emergency department, it is often impossible to determine if a patient is in the process of dying, or whether they may have a recoverable exacerbation. The use of NPPV in this setting may serve both to palliate symptoms, but also to buy time to see if the patient will improve. The balance between continued use of NPPV looking for improvement and focusing purely on comfort is complex. In these scenarios, it is essential to set specific goals and timeframes for reassessment. The potential benefits of NPPV must be balanced against the risk that it will prolong the process of dying.
Addressing secretions and the ‘death rattle’: As patients lose consciousness they lose their ability to swallow and oral secretions can pool, causing gurgling noises. There is no evidence that this is disturbing to patients, but families often have a very hard time with these noises. It can be managed by positioning the patient or with medications such as glycopyrrolate (0.2mg IV/subQ).
For some patients, a search for and treatment of potentially reversible causes may be beneficial.
|Reversible causes||Possible treatment|
|Airway obstruction (mass)||Steroids, urgent palliative radiation|
|PE||Anticoagulation (unclear if this will help symptoms)|
|Fluid overload||Diuresis, CPAP|
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A brief guide to the immediate management of severe hyperkalemia in emergency medicine and critical care
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