A Model for Emergency Department End‐of‐life Communications After Acute Devastating Events—Part II: Moving From Resuscitative to End‐of‐life or Palliative Treatment

Abstract

The model for emergency department (ED) end-of-life communications after acute devastating events addresses decision-making capacity, surrogates, and advance directives, including legal definitions and application of these steps. Part II concerns communications moving from resuscitative to palliative and end-of-life treatments. After completing the steps involved in determining decision-making, emergency physicians (EPs) should consider starting palliative measures versus continuing resuscitative treatment. As communications related to these end-of-life decisions increasingly fall within the scope of emergency medicine (EM) practice, we need to become educated about and comfortable with them.

Integrating Palliative Care in the Out-of-Hospital Setting: Four Things to Jump-Start an EMS-Palliative Care Initiative

“…The guiding principle of providing the highest quality of symptom management to all patients, and especially to those who do not receive advanced life-support or ventilator management, may be valuable when caring for such patients at the end of life. [47][48][49] In a mass casualty event, EMS generally uses a four-category triage system: red for emergent, yellow for urgent, green for nonurgent, and black for expectant. "Black" patients are those who are expected to die.…”

“…In addition, those patients with a serious medical illness before the disaster will continue to have palliative care needs and require effective communication with family. [47][48][49] Hurricane Katrina provided a stark example of the difficult decisions that may arise during a disaster. Four days after the storm, at one hospital the temperature was 100 • F with no fresh water or sanitation and no certainty of rescue.…”

“…They also recommend developing plans for just-in-time training and psychological support of responders. [47][48][49] …”

Der Palliativpatient als Notfallpatient

“…Einige Studien präsentieren unterschiedliches Über-leben in Abhängigkeit vom Stadium der Erkrankung (früh vs. fortgeschritten; [12,17]) oder von stattgefundener Reanimation [8]. Viele Autoren zielen auf eine individuelle Entscheidungsfindung mit dem Patienten, mit schriftlichen Äußerungen (Patientenverfügung, Vorsorgevollmacht; [10,16,20,28,31,32]) oder dem "surrogate decision making" mit Angehörigen [5,10,11,13,14,28] ab, um das jeweilige Therapieziel -Lebenserhalt oder Palliation -festzulegen. Dabei wird ein großer Fokus auf die Kommunikation mit dem Patienten und den Angehörigen gelegt [5,10,11,13,18,28].…”

Characterization, conservation and loss of dignity at the end‐of‐ life in the emergency department. A qualitative protocol

“…This can lead to the loss of fundamental aspects of human dignity such as confidentiality, accompaniment or privacy (Nayeri & Aghajani, ). In the light of acute conditions that threaten his/her life, the dying patient in the ED is confronted with overcrowding, stress, lack of communication, fear and loneliness (Limehouse, Ramana Feeser, Bookman, & Derse, ). In this setting, patients, relatives and healthcare professionals encounter technical interventions (Nikki, Lepistö, & Paavilainen, ), futility, therapeutic limitations (Ache, Wallace, & Shannon, ; Scanlon & Murphy, ), “Do‐Not‐Resuscitate” orders (Jesus et al., ), palliative sedation (Escalante et al., ), advanced directives (Lee & Kim, ; Scheck, ) and even the loss of dignity (Latour & Albarran, ; Molan, ).…”