Episode 5: Why Is This Dying Patient In My Resus Room?

Author: Eoghan Colgan    @eoghan_colgan
Special Guests: Calvin Lightbody    @CJblue72_



Podcast 5 Why Is This Dying Patient In My Resus Room?

Guest Bios

Calvin Lightbody

Calvin Lightbody   @CJblue72_

Dr Calvin Lightbody has been an Emergency Medicine consultant at University Hospital Hairmyres in NHS Lanarkshire since 2009. Originally a graduate of Queens University Belfast, Calvin spent his early career in GP training in Ulster before making the switch to A&E. He ended up taking his specialist training in the West of Scotland after trainee stints in Antrim, Melrose and Australia.

A long standing interest in end of life care prompted him to take the European Certificate of Essential Palliative Care at the Northern Ireland Hospice in 2015. He then spent 6 months working part time with the Palliative Care Team in Glasgow Royal Infirmary and has since applied much of what he learned to current EM practice.

He was part of the team that developed Hospital Anticipatory Care Plans (HACP) for patients who are nearing the end of life. HACP is now in common use across the NHS Lanarkshire health board.

Calvin teaches on the subject of anticipatory planning for Foundation year doctors. He has also presented several times on the topic of “Realistic Medicine” at various conferences and symposia. He is currently conducting a research project looking at medical harm in patient care at the end of life while continuing to work clinically in EM.

Show Notes

Eoghan and Calvin discuss the importance of recognising dying in the emergency department and how to do it. They also discuss the limitations of the DNACPR form and the benefit of a more personalised anticipatory care pathway. Calvin also provides his pearls on facilitating an holistic and dignified death and avoiding the common pitfalls that result in a 'bad' death.

See Also Calvin's blog on the very same topic.

Take Home Points

  • There are increasing numbers of patients with multiple morbidities presenting to hospital

  • Recognising dying is difficult

    • Imminent death may be suggested by:
      • Deteriorating physiology despite treatment
      • The appearance of the patient
      • The context of the illness (e.g. co-existing life-altering illness)
  • Recognising the end-of-life trajectory

    • What is the context of this presentation
    • How have things been going over past few months
    • What is the direction this patient is going?
  • It is important to recognise dying

    • To prevent harm to patient
      • Unnecessary treatment/investigations

    • Has a single purpose (to avoid CPR)
    • Futile in a dying patient
    • Often misunderstood – euphemism for dying
      • Care can be limited
      • Does not prompt physician to consider what the patient does require
  • Hospital Anticipatory Care Plan

    • An individualized plan for the patient
    • Addresses the appropriate and inappropriate care for the patient given the context of the presentation
  • Bad Death

    • Persist with unnecessary treatments/procedures that don’t alter outcome
    • Doctors present instead of family members
    • Insufficient dignity
    • Cared for by staff that have not introduced themselves to the patient
  • Facilitating a ‘good’ death

    • Recognising dying and the need for a different, palliative approach
    • Addressing the holistic needs of the patient
      • Physical
        • The appropriate environment for peace/dignity (side room)
        • Discontinue unnecessary observations/treatments
        • Prescribe anticipatory treatments to address the symptoms commonly experience during the dying process
          • PAIN: Morphine 2mg IV/SC PRN 1 hourly
          • SOB/Agitation: Midazolam 2mg IV/SC PRN 1 hourly
          • Secretions: Hyoscine Butylbromide 20mg IV/SC 4 hourly PRN
          • Nausea: Levomepromazine 2.5mg IV/SC
          • Agitation: Haloperidol 1mg
      • Psychological
        • What are their concerns during the dying process – anything distressing them
      • Social
        • Which family they want present at that time
      • Spiritual
        • Religious needs if appropriate
        • What else would give the patient comfort at this time
  • Communicating the dying process and pathway with patients

    • Ask patient and/or family – ‘what is your understanding of what is happening?’
      • How have things been going recently?
      • How are things now compared to 3-6 months ago
    • What is important to you and your life at this time?
    • What are your fears?
      • Is there anything you are worried about your care right now?
    • Discuss the need to move from prolonging life to preserving dignity and maintaining comfort