The EM Crit Podcast 93 on Palliative Care by Dr. Ashley Shreves is simply outstanding and every doctor and nurse can profit by listening to her lecture here. And as always with the EM Crit show notes always be sure to read all of the thoughtful reader commentaries. Here is one EM Crit reader comment that I personally found helpful:
One of Dr. Weingart’s listeners (Dr. Don Zweig) summarized the core of Dr. Shreve’s on the Podcast 93 Show Notes and I have included them below:
A listener, Don Zweig, wrote with this summary:
- We (as in ED docs) in general deal with End of Life Care and palliative care situations poorly.
- Our job as physician is to understand the family goals and values and then give a professional recommendation- it is not to give a menu–they have no medical knowledge to reasonably make this choice.
- Three things we should never say:
- “Do you want us to do everything?” Of course they do, but if you offer “everything” who wouldn’t want mom to get everything? Could they say….”no, whatever you do , don’t do everything for mom!” This also makes the family feel that everything (whatever that entails) is reasonable or possible. Instead use the ‘Pal Care’ approach and say, “What would be most important to you and your mom now?” On the basis of what you hear make a reasoned professional recommendation.
- “Do you want us to resuscitate her?” This implies that we think it is possible or reasonable to do this! Since you ask this it must be reasonable. “You can just bring her back? Great, go ahead!” Use natural death language. So it sounds like your mom would want a natural death? When her heart stops we will not interfere with that process
- ” I am so sorry, there is nothing more we can do” There is a lot that can be done and it involves maximizing comfort and minimizing suffering. They need palliative care or hospice. So call a consult and give palliative meds.
And Dr. Shreve discusses end of life dyspnea beginning at 16:40.
It is one of the most common and distressing symptoms of the dying.
The treatment of dyspnea at end of life is opiates. Opiates are the best and it is unethical to withhold them.
When used appropriately and carefully opiates do not shorten life.
So we start low and go slow.
Give 1 mg of morphine IV or maybe hydromorphone 0.2 mg IV. If it is an opiate naive patient we’re starting with 1 mg of morphine.
If the dose is not effective you can double the dose.
Repeat every 15 minutes until
- The patient reports relief
- The patient appears comfortable.
And finally Dr. Shreve gives us an incredibly useful resource for palliative care: Fast Facts and Concepts from the The Palliative Care Network of Wisconsin. [In her 2013 talk she references different links but these are the current links.]
See my post The Palliative Care Network Of Wisconsin – Direct Links To 360 Summaries Of Palliative Care Treatment Plans
Posted on February 24, 2019 by Tom Wade MD