ED Palliative Care- A Nursing Perspective
Author: Alexis Savage
Sometimes in a busy Emergency Department driven by emergency and resuscitation, we become focused on saving and preserving lives, and forget how to manage those patients that are not going to survive. It is important to remember that as nurses we are advocates for our patients, and where possible we should promote dignified and peaceful dying.
Many palliative patients present to ED for symptom management such as pain, nausea, dyspnea, that have not been well controlled at home. Other possibilities include families being unable to cope with the symptoms or emotional burden.
When caring for our palliative patients we should strip our skills right back to the basic nursing skills. Isn’t this the reason we became nurses to look after and care for our patients needs? We need to ask patients and their families questions, identify and address barriers that are effecting their care, we should listen and respond to their worries and fears. If a patients presentation causes them or their family distress it may negatively impact on their last stage of life and their memories of their loved one. The majority of patients and their families want to die symptom free and in familiar surroundings.
When in ED the dying patient doesn’t need to be in resus. We should initiate peaceful and dignified surroundings for patients and families. Side rooms, for example, should be utilised. Do we really need to distress our patient with unnecessary noise from an alarming monitor? Families should be invited in as soon as possible to accompany their relative to minimise distress for them both.
DNA CPR forms should be in situ if not already from the community.
We should work with medical staff to consider, where appropriate, whether invasive treatments such as IV lines are appropriate and whether and sub cut lines used instead. Patients home pain management regime must be considered when pain medications are given in ED, patients are often under medicated in ED. Within hours we could contact our palliative care team if available within the hospital for advice if we are unclear.
As nurses we should be observing our patients to try and identify the cause of the patients distress, and we should familiarise ourselves with treatments to minimise this. We can support medical staff by identifying symptoms to allow the appropriate management. Suggestions below are taken from local policy.
If a patient is receiving oral Morphine or a step 2 analgesic (including Co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of Morphine / Diamorphine should be available (1/6th to 1/10th of 24 hour equivalent dose). If opioid naive, consider Morphine/Diamorphine 2mg SC hourly as required (max 6 doses in 24 hours).
Nausea & vomiting
If a patient is receiving an oral anti-emetic and this is effective, then that drug should be available for SC use. See Scottish Palliative Care guidelines under Nausea & Vomiting for medication dosing advice. If the patient is not on an anti-emetic, consider Levomepromazine 2.5mg SC 8 hourly as required.
Agitation / Restlessness
Prescribe Midazolam 2mg SC hourly as required (max 6 doses in 24 hours). Midazolam 10mg/2ml ampoules should be supplied as other strengths are not used in palliative care.
If a patient is receiving oral Morphine or a step 2 analgesic (including Co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of Morphine / Diamorphine should be available (1/6th to 1/10th of 24 hour equivalent dose). If opioid naive, consider Morphine/Diamorphine 2mg SC hourly as required (max 6 doses in 24 hours)
If patient is breathless and anxious, consider the use of sublingual Lorazepam 500micrograms 4-6 hourly or Midazolam 2mg SC hourly as required (max 6 doses in 24 hours).
Prescribe Hyoscine butylbromide 20mg SC hourly as required (max 6 doses in 24 hours)
We should regularly assess our patient for physical symptoms like bladder and bowel function, to recognise and identify early treatable causes of distress.
We should carry out oral hydration and mouth care.
Where possible we should identify the patients spiritual, religious and cultural needs- for example offering chaplaincy service etc.
It is important to find out if the patient and their relatives have a plan. Do they have a preferred place of death? If a patient wants to die at home, we can initate this in A&E, we can communicate with District Nurses to ensure that patients are cared for in the community.
During and after death, it is important for the family to have quiet time to sit with their loved one. A good system we use is to place a pink butterfly on the door of the room, which alerts staff that someone is dying or has died, so that they know to be extra quiet and sensitive to their needs at this time.