Palliative care in the emergency department

1. SymptomManagementin
TheEmergencyDepartment
Ryan Cheng
2/8/18
PalliativeCare

2. Oneshoulddieproudly
whenitisnolonger
possibletoliveproudly.
Friedrich Nietzsche

3. TheProblem
Pain Delirium Dyspnoea Bladder and
Bowel
Nausea and
Vomiting

4. PainManagement:OpiateNaïve
IV
Morphine 2.5-5mg q5min
Fentanyl 25-50mcg q5min
SC
Morphine 2.5-5mg q10min
Fentanyl 25-50mcg q10min

5. PainManagement:OpiateTolerant
• Need to convert existing PO doses of opiate analgesics to IV/SC equivalent
• Breakthrough should be charted as 1
12
to 1
6
of calculated equivalence
Opioid Parenteral Oral
morphine 10 mg IV/SC 30 mg
oxycodone 10 mg IV/SC 20 mg
hydromorphone 1.5 to 2 mg IV/SC 6 mg
fentanyl 100 to 150 micrograms IV/SC –
methadone Discuss with palliative care
buprenorphine 400 micrograms IV/SC 800 micrograms sublingual
codeine – 240 mg
tapentadol – 100 mg
tramadol 100 mg intravenous 150 mg

6. PainManagement:OpiateTolerant
Patient is on Oxycodone 60mg BD
• Daily dose = 120mg
• Equivalent = Morphine 180mg PO
• SC equivalent = 60mg in 24hrs
• PRN range 1
12
to 1
6
= 5mg to 10mg morphine SC PRN
Opioid Parenteral Oral
morphine 10 mg IV/SC 30 mg
oxycodone 10 mg IV/SC 20 mg

7. PainManagement
• Re-review analgesic use in 24 hours (if still in ED…) to recalculate requirements
• Don’t forget adjuncts!
• Paracetamol
• NSAIDs

8. Delirium
• Haloperidol 1mg SC q1h PRN – max 5mg
• Midazolam 1-2mg SC q1h PRN

9. DyspnoeaandSecretions
• Opiate or benzos
• Sit patient up, or in desired position for comfort
• High flow oxygen (even in the absence of hypoxia)
• Humidified air
• Permit patient to hold mask to face rather than securing to minimize claustrophobia
• Secretions: buscopan 20mg q1h SC PRN – max 80mg

10. BladderandBowelCare
• Consider catheterization/urodome if patient is unable to mobilize to the toilet
• Remember, the Lotus room does not have facilities or readily accessible nursing staff!
• Patients without family/NOK present do not qualify for use of the lotus room
• If not imminently dying, consider laxatives for management of constipation secondary to
opiate use

11. Nauseaand Vomiting
• Metoclopramide
• Shouldn’t be used if pro-kinetic effect can worsen symptoms, i.e. bowel obstruction
• Haloperidol
• Ondansetron
• If intracranial cause, consider dexamethasone 4-8mg PO/SC OD
• Refractory nausea with multiple multimodal agents
• Dexamethasone 4mg PO OD

12. OtherComplications
• Seizures – midazolam
• Acute airway obstruction/stridor
• Dexamethasone 16mg PO/IV/SC stat
• Adrenaline nebs
• SVC obstruction or spinal cord compression
• Dexamethasone 16mg PO/IV/SC stat

13. AcuteHaemorrhage
• If active treatment is appropriate, treat as usual
• If catastrophic bleeding secondary to a terminal event (i.e. arterial erosion), active treatment
and medications unlikely to be administered in time
• Remain with the patient to provide the comfort of physical presence
• If not for active treatment, but not imminently dying
• Morphine and midazolam

14. ExamplePRNRecap(OpiateNaïve)
Morphine 2.5-5mg SC q10min
Midazolam 1-2mg SC q1h
Haloperidol 1mg SC q1h – max 5mg
Buscopan 20mg SC q1h – max 80mg
Metoclopramide 10mg SC q8h
Consider Paracetamol/NSAIDs

15. BitsandPieces
• Palliative care consultation available 24hrs
• After hours = pall care consultant (they’re really nice!)
• Flags patient for PC follow up
• Need to liaise with PC, if lotus room is desired
• Nobody should have to die alone
• Comfort from physical presence should not be underestimated
• Pre-empt dealing with the aftermath
• Liaise with SW early
• Have difficult discussions/breaking bad news with other
team members present to reiterate and explain

16. Hopedoesnotlieina
wayoutbutinaway
through.
Robert Frost