As emergency medicine residents, we work side-by-side with a wealth of specialities to gain clinical and diagnostic skills and to learn what happens to our patients when they leave the ED. We strive to distill the information we need to make ourselves better clinicians and improve the transition of patients from the ED to inpatient teams.
However, only rarely do we get to see where our patients came from, what happened prior to their ED arrival, and where they will go when they leave the hospital. Over the past month I have done just that as a senior resident on community and in-patient palliative care teams. It was more challenging and rewarding than I had ever imagined.
Below I share my top ten lessons from these experiences that I hope will make me a better emergency physician.
Having a difficult conversation? Asking difficult questions? Pause. Stop. Take a breath. Count to ten in your head. Whatever you need to do, respect the impact of a pause in difficult conversations. It will feel awkward at first, especially as your emergency medicine brain is trying to get ten steps ahead. But the effects of a well-timed, prolonged pause are vast. It demonstrates composure, patience, respect, and that you are sensitive to the difficult nature of what you are asking. It allows patients and loved ones to really process what is going on, time to gather their thoughts, to look at their loved one and take the moment in.
2) Agitation and pain are different.
But they are related, and it can often be difficult to tell them apart – especially if you do not have a good sense of what is going on with the patient medically and otherwise. As the physician, it is important to take a thorough history and do a complete exam. This, along with your clinical acumen, can help you develop a strong understanding of the patient. When treating patients who have both agitation and pain (e.g. older patient with delirium and a fracture), take a minute to educate the family and the support staff on what each looks like for your patient, and what the options are for treatment (starting with non-pharmacological options first). In patients with cognitive or sensory impairments it can be difficult for them to communicate pain, and this may lead to agitation. So be suspicious and think about why they might be agitated. In the cases of under-treated pain, treating the pain will reduce agitation.1
3) You cannot eliminate all pain.
Many physicians find patients with long term pain challenging, and understandably so. Emergency doctors are notoriously ‘doers’ and relish in the satisfaction of improving someone’s life through their actions – but a patient with long standing pain does not fit into the ‘in and out or through the ED’ model. Pain is complex! The concept of total pain is one that is common in palliative medicine, and although we don’t call it this in the ED, we see it every day.2 The experience of pain is complicated, and influenced by an individual’s physical, psychological, social, spiritual and practical suffering. It is true that a visit the ED is unlikely to cure this type of pain, but taking a few extra minutes with these patients to try to understand how their pain affects them and what triggered them to come to the ED today may help identify ways that we can help.
4) Ask the question you want answered.
Imagine you are five years old and have just been given a new colouring book which you are very excited to colour. You are given the option of two coloured markers, green or red. But, when you choose green you are handed a yellow crayon. How do you feel? Confused? Frustrated? Angry? Sad? This is what so many physicians do every day when asking patients about goals of care.
It does not have to be this way. Asking a patient who is dying from heart failure whether they would like CPR or not is NOT the relevant question. Dying is inevitable, so the question should be what they want in the moments leading up to their death? Do they want a quiet, peaceful time with their family and loved ones? Would they like to be on monitors and IV medications? Would they like a team of physicians and nurses to enter the room and for their loved ones to leave so that everything can be done to try to prolong their life, despite knowing that the chance of prolonging life is almost zero? The decisions individuals and families make are complex, embedded in a history of cultural, religious, familial and personal views, and must be respected.
5) Corticosteroids are activating – prescribe accordingly.
As emergency doctors we often prescribe corticosteroids. The evidence for their use in various conditions is variable and they often have side-effects. Even short courses will affect blood glucose control, alter appetite, trigger delirium and psychosis (rare), and have an activating effect. This activating effect leads many physicians who regularly prescribe corticosteroids to advise their patients to take them in the morning. You should do the same! No daily dose corticosteroids after 12:00.
6) Remember subcutaneous routes.
Aging changes the body, including the skin and blood vessels. This means intravenous access can be difficult, especially in sick, hypovolemic older patients. In palliative care, specialists frequently provide non-PO treatment options in home or long-term care environments where indwelling intravenous catheters are both annoying and dangerous.
The solution? Subcutaneous injection.3 Many medications can be given this route: haloperidol, metoclopramide, ondansetron, diphenhydramine, morphine, lorazepam and dexamethasone to name but a few. Remember this route as a useful option to facilitate PO intake (and potentially later intravenous placement), patient safety, and symptom relief.
7) Be smart with pain and opioid management.
Opioids are often abused, dangerous, and have side-effects. These are facts. That they can be effective analgesia and may be required in large doses are also facts.
The concern regarding opioid abuse is well founded, and I urge all physicians to continue to practice safe prescribing habits and assess patients requiring opioids closely. However, when patients with severe pain present in a pain crisis, have maximised their PRN dosing, and are still not achieving control, treat them appropriately. These patients are not like opioid naïve older patients in that they will require large doses with rapid titration to have an effect. Remember, the peak onset for oral opiods is, at most, two hours.4,5 It is even less if given via subcutaneous or intravenous routes (probably 30 and 15 minutes respectively). If you have not achieved adequate relief by the time of peak effect then why wait longer? Keep this in mind and reassess frequently patients who are having difficulty achieving adequate pain control.
8) Nausea and vomiting have more than one cause… and treatment.
Dopaminergic? Cholinergic? Serotonergic? We all learn this in medical school, and subsequently many forget it. But this one deserves the space in your brain: treating nausea appropriately not only improves the patient experience, but will also save us from the reflex treatment with costly, poorly effective and potentially harmful alternatives. There are options beyond dimenhydrinate and ondansetron.
Don’t forget your other agents (simplified by cause):
Abdominal (apart from obstruction) – Metoclopramide
Toxin/chemical/metabolic (including medication induced) – Metoclopramide, Haloperidol, Cannabinoids
Intracranial (ICP) – dexamethasone
Vestibular – dimenhydrinate or scopolamine
Psychogenic – benzodiazepine
9) Some people WANT to talk about death and dying.
When patients are approaching the end of life, they and their loved ones often know it. When given the opportunity to talk about it, ask questions, and plan, they engage. In the ED we often fear that it is the wrong time, wrong place, wrong people, or that we just don’t know how to do this effectively. Even when done right, patients may fear upsetting their loved ones, may feel judged for thinking about death, or like they are ‘giving up’. Giving people the opportunity to discuss death, feel heard, and ask questions about dying is hard, but rewarding for all involved. These are conversations that every emergency physician should consider in the appropriate patient.
10) Palliative care is NOT just end-of-life care.
In 2017 the WHO defined palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering.”6 Importantly, they do not assign a timeframe nor a disease process. There is no clear point at which ‘palliative care’ suddenly becomes the right approach, and there is no limit on who provides it. I believe that a palliative approach is a patient-centred approach for those who live with chronic, incurable disease. It is something all physicians, in the ED and beyond, can use.
Reviewing with the Staff
I think this is an excellent review of a few “top ten” learning points that anyone can add to his or her practice. The fact that it is written directly out of Brittany’s own experience as an EM resident really helps. I hope it will intrigue others to consider additional Palliative Medicine training – if only because she demonstrates clearly how that training has helped her develop an effective patient-centred approach to a complex and frequent patient group. Most emerg physicians want to help as much as they can. But most of us feel we don’t have the skills or knowledge when it comes to palliative medicine which seems so remote from emergency medicine. Brittany demonstrates how it is possible for us to do so.