Why Is This Dying Patient In My Resus Room?
Author: Calvin Lightbody @CJblue72_
Why is this dying patient in my resus room?
It’s a question commonly asked by many veteran ED doctors these days. It touches upon the frustration felt at having to deal with cases where a plan made before emergency transfer to hospital or perhaps more primary care input would have averted what can so often be an undignified experience for the patient and an addition to the day’s burdens for the doctor.
Who hasn’t heard a “stand by” call recently along the lines of “we are en route with an 85 year old dementia patient from a nursing home who has possible sepsis with worsening shortness of breath, low sats and reduced GCS”?
The unforgiving reality however is that more and more patients end up in an ED at the end of their lives. Why is this happening? Too often it is inappropriate.
The context to this situation
We all know about the aging population in the UK – in fact we’ve known about it for a generation now. More people are living longer, because modern medicine is great at keeping people alive. But this has resulted in large numbers of patients reaching advanced years with multiple co-morbidities. It is not uncommon for patients to have 3, 4, sometimes even 5 or 6 morbidities. This impacts on provision of care in acute hospitals.
Eventually such patients are on an end-of-life trajectory that can be identified weeks or months before there is a terminal event. In a recent study by the University of Glasgow 1, it was found that nearly a third of patients in Scottish acute hospitals were in the last year of life. Furthermore, nearly 1 in 10 patients admitted to hospital died during their index admission. Most of these patients will have passed through an ED like yours along the way.
Our societal reluctance to discuss the inevitability of death is allied to the “fix it” mentality among professionals – and this dictates that every patient must be fixed every time. Current models of primary care provision mean that patients nearing the end of life are sent to the ED especially during the out of hours period – to be fixed!
RCEM Best Practice Guideline
March 2015 saw the publication of the RCEM guideline on “End of Life Care for Adults in the Emergency Department” 2. Recommendation number one states that “All ED staff should receive regular training in all aspects of end of life care”.
So how much training have each of us had? How many EM trainees have had exposure to palliative medicine training? How many of our CPD sessions are directed towards this topic? We need to upgrade our practice in this area if we are going to deliver relevant as well as satisfying care to a significant proportion of the patients that we encounter.
How do I know if a patient is dying?
The imminence of dying is difficult to predict. There isn’t a simple troponin-esque biochemical marker, handy check-list or give away clue.
Many doctors have anecdotes about patients that they thought were about to die only to see them sitting up drinking tea a few hours later (the “Lazarus” experience). This uncertainty can make us uncomfortable. But, rather like leaves changing colour in autumn, while the exact time when a leaf finally falls may be uncertain, the inevitability of its eventual fall is certain. The imminence of someone’s death is not about minutes or hours: that’s often how we think in the ED. It’s about days or weeks. That judgment is critical to delivering appropriate care.
Deciding that a patient is on an “end of life trajectory” takes into account how things have been going in recent months as well as the current illness that has brought the patient into hospital. Taking a step back helps us give perspective and context to the situation that the patient that we are about to treat is in.
Of course, there will be obvious cases when, based on your experience and clinical assessment, dying is going to be soon - perhaps when there is a “non-survivable” event such as catastrophic intracranial haemorrhage.
Whatever the context, we should be prepared to do our best to determine the appropriate goals of care. We should work energetically to achieve survival and recovery when that is possible and right. But we should also ensure that in the final stages of a patient’s life, the goals are modified, that palliation and support are not regarded as second best, and that they are not on the receiving end of the harms that so often come with over-energetic futile interventions. If the current system means that a person’s last experience of living is in hospital, please let it be dignified.
More about harms
It may seem strange to be talking about harm here. But medical harm is exactly what can happen if dying is not recognised and addressed appropriately.
The Parliamentary Ombudsman’s Report from 2015 entitled “Dying without Dignity”3 makes for uncomfortable reading. It highlights that many ‘bad deaths’ in acute hospitals result from medical over-treatment. A recent systematic review 4 looking at the care of over a million patients in the last 12 months of life found that around a third of patients received non-beneficial treatments as they approached death.
In her first Scottish Chief Medical Officer report 5, Catherine Calderwood talks about the need for clinicians to practice “Realistic Medicine”. She highlights the need to avoid both ‘over treatment’ and ‘under treatment’.
Over treatment happens when investigations, procedures or interventions happen which make no difference to management or confer little meaningful benefit for the patient. Such interventions are also burdensome for the patient. Under treatment happens when a patient’s palliative care needs are delayed or neglected altogether.
Over-treatment and under-treatment often go hand in hand and may contribute to a bad death. We can avoid this situation when we recognise that the patient is on an end-of life trajectory.
Treatment Escalation / Limitation Plans
The RCEM supports the establishment of Treatment Limitation / Escalation Plans in the ED. An example of a basic treatment limitation plan is the commonly used DNACPR order. However, CPR is just one of many interventions that depending on prognosis and the patient’s wishes, may be inappropriate.
In my own health board NHS Lanarkshire, I have been part of the team that has developed a treatment escalation limitation plan known as the Hospital Anticipatory Care Plan (HACP) 6. HACP is primarily a communication tool that aims to minimise harm that can happen through discontinuity of care, futile treatments that are so often delivered out of hours. The HACP is based on prognosis, the patient’s wishes and the goals of treatment especially if what is needed is end-of-life care.
In our ED, my colleagues and I routinely use the HACP. Having the conversation about the provisions of an HACP is much easier than for DNACPR because the focus is on what you are still going to do for a patient more so than discussing the futile interventions you wish to avoid. In my experience over the last few years both patients and families value this opportunity to discuss this more realistic approach.
Management in the last hours / days of life
This section is about the care of patients who are dying imminently or who are likely to die while still in the ED 7.
The focus of the patient’s care should be on symptomatic and comfort measures only. Wherever possible and within the confines of a busy department the patient should be moved to a side room or a quieter, more peaceful area. Some EDs provide a dedicated room for this purpose.
The patient’s needs at this time can be broadly broken down in terms of physical, psychological, social and spiritual.
· Stop all non-essential medications, blood tests and clinical observations.
· Consider individualised anticipatory prescribing of medications for the common symptoms that patients have nearing the end of life (see below).
· Assess for bowel and bladder dysfunction – these can be treatable causes of distress.
· Review hydration needs – encourage oral fluids where possible, accepting that risk of aspiration may be higher.
· Regular mouth care – try to keep the mouth moist and comfortable.
· Find out who and what is important to the patient. The presence of relatives / carers / friends should be encouraged and supported.
· Where is the patient’s preferred place of death? If home – can this be arranged and supported?
· Keep family / carers / friends and the patient (whenever possible) updated about the current situation. Ask about worries or fears, taking time to listen and respond.
· Consider that “agitation” may have spiritual as well as physical causes.
· Offer to contact the chaplaincy service or their preferred faith leader.
· The patient may have other non-faith based sources of comfort or support. Enquire if this may be the case.
Anticipatory Medication Prescribing:
Write up the following medications in the ‘as required’ section of the drug Kardex. All drugs can be administered via the subcutaneous or intravenous route.
1. MORPHINE 2mg, hourly PRN – for pain or breathlessness
2. MIDAZOLAM 2mg, hourly PRN – for anxiety / agitation
3. HYOSCINE (Buscopan) 20mg, maximum of 6 doses in 24hrs – for secretions
4. LEVOMEPROMAZINE 2.5mg (two point five), 8 hourly PRN – for nausea
5. HALOPERIDOL 1mg, 12 hourly PRN for agitation / delirium
Death and dying may involve suffering and distress. However, taking this approach means it is much more likely that the patient will have a good rather than a bad death. It also means that this stage of the bereavement process is less traumatic for family members. They will remember the circumstances of their loved one’s dying: was it chaotic and harrowing or dignified and peaceful? For the clinician taking care of them, there can be satisfaction in providing for a “good death”. There is only one chance to get it right doing it well is rewarding. That has certainly been my experience in recent years.
1.) Clark, D et al. Imminence of death among hospital inpatients: Prevalent cohort study. Palliative Medicine Journal. Volume: 28 issue: 6, page(s): 474-479. https://doi.org/10.1177/0269216314526443
2.) RCEM Best Practice Guideline- March 2015. End of Life Care for Adults in the Emergency Department. https://doi.org/10.1177/0269216314526443
3.) The Parliamentary Ombudsman’s Report 2015: Dying without Dignity.
4.) Cardona-Morrell, M., Kim, JCH., Turner, RM., Anstey, M., Mitchell, IA., & Hillman, K. (2016). Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. International Journal for Quality in Health Care Advance Access, 1 – 14. https://doi.org/10.1093/intqhc/mzw060
5.) The Chief Medical Officer for Scotland’s Annual Report 2014/5: “Realistic Medicine”. : http://www.gov.scot/Resource/0049/00492520.pdf
6.) HACP At Point of Admission
7.) Care and Dignity for the Dying Patient
See also Calvin's podcast on this very topic!