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PALLIATIVE CARE IN
THE ED
AGS
Jessica Stetz, MD, MS
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
WHO DEFINITION
OF PALLIATIVE CARE (1 of 3)
Improves quality of life of patients and families
facing problems associated with life-threatening
illness, through prevention and relief of suffering
by early identification and impeccable
assessment and treatment of pain and other
problems, physical, psychosocial and spiritual
Slide 2
WHO DEFINITION
OF PALLIATIVE CARE (2 of 3)
• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten nor postpone death
• Integrates psychological and spiritual aspects of care
• Offers a support system to help patients live as actively
as possible until death
• Offers a support system to help family cope during patient
illness and in bereavement
Slide 3
WHO DEFINITION
OF PALLIATIVE CARE (3 of 3)
• Uses team approach to address needs of patients and
families, including bereavement counseling
• Will enhance quality of life, and may positively
influence the course of illness
• Is applicable early in course of illness, in conjunction
with other therapies intended to prolong life, such as
chemo or RT
• Includes investigations to understand and manage
distressing clinical complications
Slide 4
CHRONIC DISEASE PROCESSES/
LIFE-LIMITING ILLNESSES
• Cancer
• CHF
• COPD
• CVA
• ESRD
• PVD
• DM
• AIDS
• Dementia
• ALS
Slide 5
PALLIATIVE CARE PARADIGM
Life-prolonging care
Medicare
Hospice
Benefit
Old
Disease progression
Life-prolonging
care
Hospice Care
New
Palliative care
Diagnosis of serious illness
Death
Slide 6
ADVANTAGES OF PALLIATIVE CARE
IN THE ED
• Clarify/change goals of care
• Resolve conflict
• Decompression of ED overcrowding by limiting ICU
consults/admissions in patients with advanced
disease, improving throughput
• Improve quality of life and quality of death
• Improve patient (and physician) satisfaction with care
• Decrease costs
Slide 7
TAKE-HOME POINTS
• Treat symptoms
• Communicate
• End-of-life planning
Slide 8
NEW YORK STATE
DNR ORDER
• DNR order in effect only at the point of cardiac
arrest
• DNR may be revoked by patient at any time
• DNR does not necessarily equal DNI
• DNR does NOT mean do not treat
 In-hospital DNR forms are not standardized
 Out-of-hospital DNR orders are standardized
• Form
• Bracelet
• Medical orders for life-sustaining treatment
(MOLST)
Slide 9
MEDICAL ORDERS FOR LIFESUSTAINING TREATMENT (MOLST)
• Based on POLST (physician orders), developed at
Oregon Health & Science University in 1991
• POLST paradigm in effect in 37 states
• MOLST pilot program in New York State in 2006 in
2 counties
• Implemented across New York State in 2008
• Bright pink form
• Placed on patient’s refrigerator
• Honored by EMS
Slide 10
ADVANCED CARE PLANNING (ACP)
• Often not addressed
• Patients may want to address ACP in ED
• Interviews of 111 consecutively admitted cancer patients
 33% had completed advance directive
 9% (10/111) reported having discussed end-of-life care
with oncologist
 Only 23% of remainder (23/101) wished to talk to
oncologist
 58% wanted to discuss ACP on hospital admission
Lamont EB, Siegler M. J Palliat Med. 2000;3:27-35.
Slide 11
PROBLEM LIST
• AMS
 Mass lesion
 Toxic metabolic
 Infectious
• Dehydration
• Pain
• Multiple myeloma
Slide 12
SIMULATION CASE
Slide 13
HEALTH CARE PROXY (1 of 2)
Health Care Proxy
(1) I, ____________________________________________________________________________________
hereby appoint _________________________________________________________________________
(name, home address and telephone number)
_____________________________________________________________________________________
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I
become unable to make my own health care decisions.
(2) Optional: Alternate Agent
If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby
appoint ______________________________________________________________________________
(name, home address and telephone number)
_____________________________________________________________________________________
_____________________________________________________________________________________
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.
(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you
want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions):
______________________________________
___________________________________________________________________________________
(4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If
you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations
here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional
pages as necessary): ___________________________
.
Slide 14
HEALTH CARE PROXY (2 of 2)
(5) Your Identification (please print)
Your Name ____________________________________________________________________________
Your Signature__________________________________________________ Date _________________
Your Address___________________________________________________________________________
(6) Optional: Organ and/or Tissue Donation
I hereby make an anatomical gift, to be effective upon my death, of:
(check any that apply)
■ Any needed organs and/or tissues
■ The following organs and/or tissues _____________________________________________________
___________________________________________________________________________________
■ Limitations_________________________________________________________________________
If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to
make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.
Your Signature____________________________ Date________________________________________
(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will.
He or she signed (or asked another to sign for him or her) this document in my presence.
Date_____________________________________ Date________________________________________
Name of Witness 1
Name of Witness 2
(print)___________________________________ (print)______________________________________
Signature________________________________ Signature___________________________________
Address__________________________________ Address_____________________________________
________________________________________ ___________________________________________
State of New York
Department of Health
1430 4/08
Slide 15
LIVING WILL
A sample living will, copyright by the New York
Bar Association, appears at www.nysba.org
Slide 16
NEW YORK STATE
SURROGATE LIST
• Health care agent (proxy)
• Power of attorney
• Spouse
• Adult child
• Parent
• Adult sibling
• Close friend (with affidavit)
Slide 17
SIMULATION CASE
Slide 18
PAIN MANAGEMENT
How do we manage pain
in the setting of hypotension?
Slide 19
PRINCIPLE OF DUAL EFFECT
• Morphine treats pain (intended effect)
• May lower blood pressure (unintended, but
anticipated consequence)
• In fact, symptom control appears to improve
survival (more morphine, patients lived longer)
Campbell M, et al. Crit Care Med. 1999;27:73-77.
Campbell M. AACN Adv Crit Care. 2008;19:340-344.
Slide 20
OPIOID PHARMACOLOGY
• Cmax
 IV = 6 min
 SC or IM = 30 min
 PO = 1 hour
 NOT including extended release
Slide 21
EQUIANALGESIC DOSING
Agonist
Route
Equianalgesic
dose, mg
Onset,
min
Peak effect,
min
Duration of
effect, hr
Morphine
IV
PO
10
30
510
1560
1030
90120
35
4
Hydromorphone
IV
PO
1.5
7.5
520
1530
1530
90120
34
46
Oxycodone
PO
20
1530
3060
46
Codeine
IM
PO
120
200
1030
3045
90120
60
46
34
Slide 22
MORE OPIOID PHARMACOLOGY
• Morphine 3:1, oral : parenteral
• Opioids are metabolized in liver, cleared by
kidney
• CrCl < 50, decrease dose
• End-stage renal disease, CrCl < 10, give 25%
dose
• Geriatric patients, give half dose
Slide 23
MORPHINE DOSING (1 of 2)
Opioid-naïve, acute pain
• Morphine 0.1 mg/kg is standard recommendation
• May be inadequate
Bijur P, et al. Ann Emerg Med. 2005;46:362-336.
Birnbaum A, et al. Ann Emerg Med. 2007;49:445-453.
Slide 24
MORPHINE DOSING (2 of 2)
Opioid-tolerant (on opioids for 72 hours)
• 10% of total daily dose for breakthrough pain
 For ex, MS Contin 90 mg BID, MS IR 30 mg Q4
• Total daily dose 360 mg PO = 120 mg IV
• Breakthrough dose = 12 mg IV
Slide 25
SIMULATION CASE
Slide 26
HYPERCALCEMIA OF MALIGNANCY
• Most commonly associated with multiple
myeloma, breast cancer, lung cancer
• Increased osteoclastic activity in bone
• Occurs in 20%30% of cancer patients
• Poor prognosis (1-year survival 10%30%)
 50% die within 30 days, 75% within 3 months
 Prognosis depends on treatment of underlying
malignancy
Slide 27
SYMPTOMS
• Nausea/vomiting (groans)
• AMS (moans)
• Abdominal/flank pain (stones)
• Weakness/myalgias (bones)
• Constipation
• Polyuria
• Headache
Slide 28
PRECIPITANTS
Geriatric principle of polypharmacy
• What medications is this patient taking?
Slide 29
PRECIPITANTS
Geriatric principle of polypharmacy
• Thiazide diuretics
 Increase calcium reabsorption
 Decrease calciurias
• Calcium carbonate
• Lithium
• Theophylline
Slide 30
HYPERCALCEMIA
• Mild < 12 mg/dL
• >14 mg/dL requires treatment
• Hypoalbuminemia
 Total serum Ca normal
 Ionized Ca elevated
• Hyperalbuminemia
 Severe volume depletion or MM
 Elevated total Ca
 Normal ionized Ca
• Corrected Ca = 0.8 (4  pt’s albumin) + pt’s serum Ca
(mdcalc.com)
Slide 31
TREATMENT OF HYPERCALCEMIA
• Hydration (RF may require HD)
• Stop agents that increase calcium or decrease
calciurias (eg, hydrochlorothiazide)
• Inhibit osteoclastic activity
• Inhibit bone resorption
• Limit enteric absorption
• Treat underlying cause (when possible)
Slide 32
BISPHOSPHONATES
• Bind hydroxyapatite
• Prevent osteoclastic activity
• Inhibit bone resorption
• Onset of action 14 days; last up to 1 month
• Pamidronate
 60 mg IV over 4 hr
 90 mg IV over 24 hr
• Zoledronic acid 15 mg IV over 15 min
Slide 33
CALCITONIN
• Naturally occurring hormone
• Inhibits bone resorption
• Increases calcium excretion
• Onset 12 hours, peak 1224 hours
• Salmon calcitonin more potent than human
 28 U/kg IM/SC q612 hr
Slide 34
SIMULATION CASE
Slide 35
GOALS OF CARE
AND DISPOSITION
• ICU
• Floor admission
• Discharge home
Slide 36
HAZARDS OF
HOSPITALIZATION (1 of 2)
• Immobilization and deconditioning
 1 day of bed rest requires 3 days of rehab
 10% of muscle strength lost each week
• Decreased plasma volume
• Accelerated bone loss
• Sensory deprivation
 Glasses
 Hearing aids
 Dentures
Slide 37
HAZARDS OF
HOSPITALIZATION (2 of 2)
• Barriers and tethers
• Urinary incontinence
• Skin breakdown
• Depression
• Functional decline
• Previous level of mobility difficult to regain
• Unable to remain independent, nursing home
placement
Creditor MC. Ann Intern Med. 1993;118:219-223.
Slide 38
HOSPICE CARE
• System of care for terminally ill patients
 With estimated prognosis <6 months
• Relieve suffering and improve quality of life for
patients with advanced illness and their
families
• Offered simultaneously with all other
appropriate medical treatment
• 98% provided at home
Slide 39
MEDICARE HOSPICE BENEFIT
AS OF 2007
• > 4700 US hospice programs
• > 1.4 million Americans utilized
• 90% hospice recipients were over age 65
• 85% hospice provided by Medicare
• Many ED patients could benefit from hospice
Slide 40
BENEFITS OF HOSPICE CARE
•
•
•
•
•
•
•
•
24/7 access to on-call RN
Home visits
In-patient and respite visits when needed
Social worker, chaplain/religious support, home
visits
Payment for medications related to hospice
98% provided at home
Bereavement for family for 13 months
Medicare still pays for care not related to hospice
(eg, broken arm)
Slide 41
ED HOSPICE REFERRAL
• Would you be surprised if the patient died in
the next 6 months?
• Florida pilot program — presented at SAEM
meeting 2009
• University of Florida at Jacksonville
• Direct referral to hospice decreased ED
congestion, improved patient satisfaction
Slide 42
HOSPICE PATIENTS
MAY LIVE LONGER
In a March 2007 study, hospice patients lived
an average of 29 days longer than non-hospice
patients
• Retrospective statistical analysis of 4500 patients
with CHF, 5 types of cancer
Connor SR, et al. J Pain Symptom Manage. 2007;33:238-246.
Slide 43
HEALTH CARE ECONOMICS
• 30% of annual Medicare costs is spent on 5%
of beneficiaries who will die that year
• 1/3 of that 30% is spent in the last month of
life
Slide 44
END-OF-LIFE (EOL) CONVERSATIONS
MAY DECREASE COSTS
• A longitudinal multi-institutional study of 603 pts with
advanced cancer and their caregivers interviewed and
followed up through death
• 188 (31.2%) reported EOL discussions at baseline
• Mean aggregate costs were $1876 for patients who reported
EOL discussions vs. $2917 for patients who did not (P =.002)
• Higher costs equaled worse quality of death in final week as
reported by caregiver (more mechanical ventilation,
resuscitation, admission to and death in the ICU)
Zhang B, et al. Arch Intern Med. 2009;169:480-488.
Slide 45
IF PALLIATIVE CARE AWARENESS
IN THE ED INCREASES:
• Improved symptom control
• Greater patient/physician satisfaction
• Fewer end-stage patients admitted to ICU
 Decreased ED congestion
• More humane clinical care and more rational
financial outcomes
Slide 46
TAKE-HOME POINTS
• Treat symptoms
• Communicate
• End-of-life planning
Slide 47
ACKNOWLEDGEMENTS
•
•
•
•
•
Brian Gillett
Cat Tubridy
Che Ward
Ed Porosnicu
John Adelaine
Slide 48
BIBLIOGRAPHY
• Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new Subspecialty, new
opportunities. Ann Emerg Med. 2009;54:94-102.
• Chan GK. End-of-life models and emergency department care. Acad Emerg Med.
2004;11:79-86.
• Lamont EB, Siegler M. Paradoxes in cancer patients’ advanced care planning. J Palliat Med.
2000;3:27-35.
• Quest TE, Bone P. Caring for patients with malignancy in the emergency department: patientprovider interactions. Emerg Med Clin North Am. 2009;27:333-339.
• Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from
mechanical ventilation: a prospective study. Crit Care Med. 1999;27:73-77.
• Campbell M. Treating distress at the end of life: the principle of double effect. AACN Adv Crit
Care. 2008;19;340-344.
• Bijur P. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in
the majority of patients. Ann Emerg Med. 2005;46:362-336.
• Birnbaum A, Esses D, Bijur PE, Holden L, Gallagher EJ. Randomized double-blind placebocontrolled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in
emergency department patients with moderate to severe acute pain. Ann Emerg Med.
2007;49:445-453.
• Creditor M. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-223.
• Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice
patient survival among patients who die within a three-year window. J Pain Symptom
Manage. 2007;33:238-246.
• Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life:
associations with end-of-life conversations. Arch Intern Med. 2009;169:480-488.
Slide 49
THANK YOU FOR YOUR TIME!
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Slide 50