The document discusses integrating palliative care in the emergency department. It begins with an outline of topics to be discussed, including how early identification of end-of-life state can reduce low-value emergency care, how to integrate discussions of goals of care and advance care planning with families of resuscitation patients, and how to optimize treatment planning to reduce inappropriate CPR attempts. It then summarizes a study which found that among patients who underwent emergency resuscitation, palliative care was associated with fewer life-sustaining treatments and less medical expenses and utilization compared to standard care. The document discusses recognizing when a patient is actively dying, common reasons palliative care patients present to the emergency department, and palliative care skills relevant
45 minutes of suffering (or Anesthesia Grand Rounds on Palliative Care)Mike Aref
Presentation on what palliative care is, comparison with hospice, primary palliative care screening, goals-of-care, definitions of DNR, basics of acute pain management and WHO analgesic ladder.
International Association for Hospice and Palliative Care (IAHPC) – Международная ассоциация хосписной и паллиативной Помощи – некоммерческая организация, которая занимается развитием паллиативной помощи по всему миру.
Одно из приоритетных направлений работы ассоциации - образование. Во многих странах учебники по паллиативной помощи дороги или труднодоступны, поэтому IAHPC бесплатно распространяет руководство по паллиативной помощи.
Пока мы выкладываем это руководство на английском языке, но надеемся вскоре перевести его на русский - с вашей помощью, с помощью жертвователей и наших друзей.
Вы тоже можете помочь фонду - достаточно отправить СМС на номер 3443 со словом Вера и суммой пожертвования. Например, Вера 100.
Также пожертвование можно сделать через Пейпал, Яндекс-деньги, или просто кредитной карточкой - все варианты есть у нас на сайте hospicefund.ru/help
Risk profiling, multiple long term conditions & complex patients, integrated ...Dr Bruce Pollington
Dr Bruce Pollington web-ex presentation to LTC QIPP programme
Utilising risk profiling, and risk stratification to identify patients with multiple long term conditions requiring complex care through integrated care teams.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
45 minutes of suffering (or Anesthesia Grand Rounds on Palliative Care)Mike Aref
Presentation on what palliative care is, comparison with hospice, primary palliative care screening, goals-of-care, definitions of DNR, basics of acute pain management and WHO analgesic ladder.
International Association for Hospice and Palliative Care (IAHPC) – Международная ассоциация хосписной и паллиативной Помощи – некоммерческая организация, которая занимается развитием паллиативной помощи по всему миру.
Одно из приоритетных направлений работы ассоциации - образование. Во многих странах учебники по паллиативной помощи дороги или труднодоступны, поэтому IAHPC бесплатно распространяет руководство по паллиативной помощи.
Пока мы выкладываем это руководство на английском языке, но надеемся вскоре перевести его на русский - с вашей помощью, с помощью жертвователей и наших друзей.
Вы тоже можете помочь фонду - достаточно отправить СМС на номер 3443 со словом Вера и суммой пожертвования. Например, Вера 100.
Также пожертвование можно сделать через Пейпал, Яндекс-деньги, или просто кредитной карточкой - все варианты есть у нас на сайте hospicefund.ru/help
Risk profiling, multiple long term conditions & complex patients, integrated ...Dr Bruce Pollington
Dr Bruce Pollington web-ex presentation to LTC QIPP programme
Utilising risk profiling, and risk stratification to identify patients with multiple long term conditions requiring complex care through integrated care teams.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
Palliative care white paper for RegenceErin Codazzi
Writing this white paper for Regence was a humbling experience, connecting directly with the doctors, nurses, nonprofits and industry influencers dedicated to elevating the awareness for palliative care. It's an important topic and one every one of us should start talking about, as daunting as it may be. Grateful to the team at Regence for letting me dig deep on this one. Read the press release: http://news.regence.com/releases/regence-blueshield-releases-findings-on-the-importance-of-a-holistic-approach-to-palliative-care
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
Presentation on palliative care given at the Caregiver's Conference for the Cystic Fibrosis Affiliate and Satellite Sites at Riley Children's Hospital.
Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
Cancer Patients Awareness of Extent of Disease-Association with Psychological...Dr. Liza Manalo, MSc.
What is already known on this topic
►► In Southeast Asian cultures, the fear that should patients know their poor prognosis, they might become depressed, worry excessively, or lose the will to live has traditionally led families to request physicians for non-disclosure of diagnosis and prognosis.
►► The Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH) studies in other Asian countries revealed that patients who were aware or unsure of their prognosis reported higher levels of anxiety and depressive symptoms.
What this study adds
►► One of the most important findings in this study was the absence of an association between advanced cancer patients’ awareness of the extent of the disease and psychological morbidity.
►►Contrary to what might be expected, awareness of advanced cancer was associated with higher social well-being.
How this study might affect research, practice, or policy
►► The results of this research could impact how doctors in this cultural context communicate with cancer patients and allay concerns among families that sharing a cancer diagnosis and prognosis with the patient could lead to distress or worry. Future studies could focus on examining the effect of cultural beliefs and values, such as faith and spirituality, and social support networks on the well-being of cancer patients.
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
Palliative care white paper for RegenceErin Codazzi
Writing this white paper for Regence was a humbling experience, connecting directly with the doctors, nurses, nonprofits and industry influencers dedicated to elevating the awareness for palliative care. It's an important topic and one every one of us should start talking about, as daunting as it may be. Grateful to the team at Regence for letting me dig deep on this one. Read the press release: http://news.regence.com/releases/regence-blueshield-releases-findings-on-the-importance-of-a-holistic-approach-to-palliative-care
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
Presentation on palliative care given at the Caregiver's Conference for the Cystic Fibrosis Affiliate and Satellite Sites at Riley Children's Hospital.
Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
Cancer Patients Awareness of Extent of Disease-Association with Psychological...Dr. Liza Manalo, MSc.
What is already known on this topic
►► In Southeast Asian cultures, the fear that should patients know their poor prognosis, they might become depressed, worry excessively, or lose the will to live has traditionally led families to request physicians for non-disclosure of diagnosis and prognosis.
►► The Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH) studies in other Asian countries revealed that patients who were aware or unsure of their prognosis reported higher levels of anxiety and depressive symptoms.
What this study adds
►► One of the most important findings in this study was the absence of an association between advanced cancer patients’ awareness of the extent of the disease and psychological morbidity.
►►Contrary to what might be expected, awareness of advanced cancer was associated with higher social well-being.
How this study might affect research, practice, or policy
►► The results of this research could impact how doctors in this cultural context communicate with cancer patients and allay concerns among families that sharing a cancer diagnosis and prognosis with the patient could lead to distress or worry. Future studies could focus on examining the effect of cultural beliefs and values, such as faith and spirituality, and social support networks on the well-being of cancer patients.
Discusses human life & human dignity, beginning of life issues like abortion and In Vitro Fertilization, as well as end of life issues like euthanasia, physician assisted suicide and
allowing natural death
Care of persons in the critical and terminal phases of life. With quotes from Samaritanus bonus, letter of the Congregation of the Doctrine of the Faith
Climate change protection of the environment-biosphere-biodiversity-laudato siDr. Liza Manalo, MSc.
Bioethics 1- Protection of the environment, biosphere and biodiversity in relation to the Sustainable Development Goals, climate change, conflict, health, and education.
The anthropological, philosophical and Christian teaching on human sexuality, marriage and the family. The Injustices of the Surrogacy Industry based on Catholic teaching on surrogacy is receiving reinforcement from current research.
End of life issues in advanced heart failure manalo palliative careDr. Liza Manalo, MSc.
Why aren’t countries accountable to commitment on end of life (#EOL) care for vulnerable people?
For lack of know-how. This presentation aims to teach cardiologists how to provide good palliative care to their patietnts.
Considerations when deciding about withholding or withdrawing life-sustaining...Dr. Liza Manalo, MSc.
Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. I n t e g r a t i n g P a l l i a t i v e
C a r e i n t h e
E m e r g e n c y D e p a r t m e n t :
A P a r a d i g m S h i f t
Maria Fidelis Manalo, MD, MSc.
Palliative Care
The Medical City
2. P r e s e n t a t i o n
o u t l i n e
TOPICS TO BE DISCUSSED:
• How can early identification of the end-of-life state
reduce low-value emergency care?
• How can we integrate discussions about goals of
care, shared decision-making, and advance care
planning with the families of resuscitation patients?
• How can we optimize emergency treatment
planning to help reduce inappropriate CPR
attempts?
3. Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Methods
• A matched-pair retrospective cohort study was conducted to examine the association between
palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier
survival analyses.
• Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services
(palliative care group) under a universal health insurance scheme.
• Retrospective cohort matching was performed with those who received standard care at a ratio of
1:4 (usual care group).
• Outcome variables included:
• Number of visits to emergency and outpatient departments
• Hospitalization duration
• Total medical expenses
• Utilization of life-sustaining treatments
• Duration of survival following ED triage level I resuscitation
Lin, CY., Lee, YC. BMC Palliat Care, 2020
4. Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Results
• The mean survival duration following level I resuscitation was less than 1 year.
• Palliative care was administered to 15% of the resuscitation cohort.
• The palliative care group received significantly less life-sustaining treatment than did the usual care
group.
Conclusion
• Among patients who underwent level I resuscitation, palliative care was inversely correlated with
the scope of life-sustaining treatments.
• Furthermore, triage level I resuscitation status may present a possible new field for starting
palliative care intervention and reducing low-value care.
Lin, CY., Lee, YC. BMC Palliat Care, 2020
5. People Enter The ED
In Search Of Help
When A Medical Or
Surgical Emergency
Arises
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-
palliative-care-in-the-emergency-department-a-paradigm-shift/
•They arrive suffering from pain, respiratory
distress, with symptoms of a stroke or heart
attack, or as the victim of a motor vehicle
accident.
•These are the patients that ED physicians
and nurses have been trained to stabilize
and resuscitate; this is where the
adrenaline kicks in and the team jumps into
action.
•While ED staff are trained to save lives, all
too often they are also faced with
situations where the usual approach—
do everything and anything to prolong
life—may add to suffering with little to no
likelihood of benefit.
6. Recognizing
"Actively Dying" or
"Imminent Death"
• It is important for healthcare providers to be
familiar with this process:
– so they know what to expect when providing
direct care to patients during this time
– so they can guide the family in understanding what
to expect during this process and providing support
as needed
• The timeline for each patient is variable.
A patient may experience these signs and
symptoms over 24 hours or for longer than 14
days.
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].
7. • Early stage: Loss of mobility and becoming bed bound; loss of interest or ability to drink and
eat; cognitive changes to include increased time sleeping or experiencing delirium. Delirium
can be a hyperactive or agitated state or a hypoactive state. The trademark point of delirium
is there is an acute change in the level of arousal.
• Middle stage: Further decline in mental status to becoming obtunded or slow arousal with
stimulation and only brief periods of wakefulness. Patients often exhibit the "death rattle"
which a noisy breathing pattern caused by a pooling of oral secretions due to the loss of the
swallowing reflex.
• Late stage: Coma; fever, possibly due to aspiration pneumonia; an altered respiratory
pattern which can be periods of apnea alternated with hyperpnea or irregular breathing;
and mottled extremities due to the constriction of the peripheral circulation
Recognizing "Actively Dying" or "Imminent Death"
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].
10. As an entry point to care, the ED is uniquely positioned to
identify the real needs of the patient and the family
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-palliative-care-in-the-emergency-department-a-paradigm-shift/
Historically, however, ED clinicians have avoided goals of care conversations about
what is most important to the patient and family, assuming these were the domain of
the primary care clinicians or their hospital colleagues.
ED staff, in turn, suffered from varying degrees of moral distress and frustration at
their inability to meet their patient’s true needs in situations where the usual
approach to disease treatment appears to be doing more harm than good—by adding
stress and suffering without meaningful gain in survival, function, or quality of life.
11.
12. Palliative Care In The
Emergency Department:
An Oxymoron Or
Just Good Medicine?
13. What is Palliative Care?
• Palliative care is an approach to patient/family/caregiver-centered health
care that focuses on optimal management of distressing symptoms, while
incorporating psychosocial and spiritual care according to
patient/family/caregiver needs, values, beliefs, and cultures.
• The goal of palliative care is to
• Anticipate, prevent, and reduce suffering
• Promote adaptive coping
• Support the best possible quality of life for patients/families/caregivers, regardless
of the stage of the disease or the need for other therapies
14. What is Palliative Care?
Palliative care can begin at diagnosis; be delivered concurrently with
disease-directed, life-prolonging therapies; and facilitate patient
autonomy, access to information, and choice.
Palliative care becomes the main focus of care when disease-directed,
life-prolonging therapies are no longer effective, appropriate, or desired.
15. Palliative Care Is NOT Synonymous With
End-of-life Care or Hospice Care
• Whereas palliative can begin at any point along the cancer care
continuum, hospice care begins when curative treatment is no longer the
goal of care and the sole focus is quality of life.
• Palliative care can help patients and their loved ones make the transition
from treatment meant to cure or control the disease to hospice care by:
• preparing them for physical changes that may occur near the end of life
• helping them cope with the different thoughts and emotional issues that arise
• providing support for family members
• Hospice care is always palliative, but not all palliative care is
hospice care.
Image courtesy of http://www.ersj.org.uk/content/32/3/796.full
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
16. When Is Palliative Care Used In Patient Care?
EARLY IN THE ILLNESS PROCESS
17. Who Gives Palliative Care?
• Palliative care should be provided by the primary
care team and augmented as needed by
collaboration with an interprofessional team of
palliative care experts.
• Palliative care specialists have received special
training and/or certification in palliative care.
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet#when-is-palliative-care-used-in-cancer-care
18. Palliative Care Skills Relevant to ED Practice
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
19. - Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
Palliative Care Skills Relevant to ED Practice
20. Palliative Care Skills
Relevant to ED Practice
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
21. M a n a g i n g T h e p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s T o T h e E D
22. Palliative Care Referral
• Limited treatment options
• Concerns about decision
making capacity
• Need for clarification of goals
of care
• Resistance to engage in
advance care planning
• High risk of poor pain
management
• High non-pain symptom
burden
• High distress score
• Need for invasive procedures
• Frequent ER visits or hospital
admissions
• Need for ICU-level care (multi-
organ failure or prolonged MV
support)
24. Pain
Assessment
O P Q R S T
O - Onset
P - Provocative factors, Palliative factors
Q – Quality
R – Radiation, Referral pattern, Location
S - Severity or Intensity
T – Timing: onset, duration, course, persistent, or intermittent
Q – Quality
25.
26.
27. DYSPNEA CRISIS
COMFORT: Mnemonic Summarizing Key Palliative Management
- An Official American Thoracic Society Workshop Report: Assessment and Palliative Management of Dyspnea Crisis, Mularski RA et al, 2013
C: CALL for help.
Calming voice and
approach among
patient and caregivers
O: OBSERVE
closely and assess
dyspnea for ways to
respond
M: MEDICATIONS
to be tried
(recommendations
from providers for
opioid/other use)
F: FAN to face
may decrease shortness
of breath
O: OXYGEN therapy
as previously found
useful
R: REASSURE
and use relaxation
techniques
T: TIMING interventions
to reduce dyspnea–
work together–
reassess–repeat
Treat Distressing Symptoms
28. • Comfort care is often used in a misleading or
imprecise manner — for example, when such
care is automatically considered equivalent to a
Do-Not-Resuscitate order and, perhaps even
without discussion with the patient, is
extrapolated to mean the exclusion of a full
range of palliative measures appropriate for
the patient.
• Rather than simply writing orders for “comfort
care” (or “intensive comfort measures,” the
term that we prefer), the medical team should
review the entire plan of care and enter explicit
orders to promote comfort and prevent
unnecessary interventions.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015
U n d e r s t a n d i n g
C o m f o r t C a r e
29. U n d e r s t a n d i n g
C o m f o r t C a r e
• Infrequently, a focus on comfort care may
include the use of potentially life-
sustaining measures, when these are
consistent with a patient’s goals (e.g.,
when the patient wants to be kept alive
with mechanical ventilation until a loved
one can visit from afar or when
withdrawing a treatment conflicts with
the patient’s religious beliefs or cultural
norms).
• In addition, the use of invasive
interventional procedures, such as
thoracentesis for the treatment of
symptomatic pleural effusions, can
promote comfort.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015
30. An Official American Thoracic Society Statement: Update on the
Mechanisms, Assessment, and Management of Dyspnea
31. O p i o i d s a n d D y s p n e a
• Opioids have been the most widely studied agent in the
treatment of dyspnea.
• Opioids treat dyspnea through many mechanisms:
–Reducing respiratory drive
–Reducing anxiety
–Altering central responses to exertion
–Cough suppression
- American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
Chest 2010;
- Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline
from the American College of Physicians. Ann Intern Med 2008;
- Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. BMJ
2003.
32. O p i o i d P a i n
M e d i c a t i o n :
S e p a r a t i n g M y t h
f r o m R e a l i t y
• Symptom-titrated opioids do not hasten death.
• With proper titration, clinically significant
respiratory depression does not occur because
pain is a powerful respiratory stimulant and
counteracts the narcotic-induced depression.
• Because pain is a stimulus to respiration,
clinically significant respiratory depression is
rare.
• Pain is nature's own antidote to respiratory
depression.
- Fohr, SA, Journal of Palliative Medicine, 1998
33. T r e a t D i s t r e s s i n g
S y m p t o m s
Delirium and agitation
Nausea and vomiting
Pruritus and sweating
Cough and hemoptysis
Constipation and malignant bowel obstruction
Chronic wounds, including malodorous or bleeding malignancy-related wounds
Acute urinary retention
34. If rapid decisions are required
regarding the use of life sustaining
treatments (e.g., intubation for
respiratory failure), whenever
possible, taking a few minutes to
clarify the patient’s goals and
preferences first, before discussing
actual decisions, can help others
engage in decision-making.
M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o
P r e s e n t s T o T h e E D
35. G u i d e F o r A n E f f i c i e n t D i s c u s s i o n O f
G o a l s O f C a r e I n T h e E D
1. Determine the legal decision maker.
If the patient is unable to make decisions, identify the appropriate
proxy/surrogate. Review any completed advance directives.
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
36. G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
2. Explain the prognosis. Discuss the "big picture."
Be clear; avoid vague language. If the condition is
incurable, say so.
•Frame the discussion as "hoping for the best
while preparing for the worst."
•Answer 2 key questions: What is wrong with the
patient? What will happen?
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
37. Issues that naturally arise during
conversations about goals of care
include the following:
Resuscitation
orders/code status
Use of invasive and noninvasive
diagnostic tests or treatments
(e.g., mechanical and
noninvasive ventilation,
hemodialysis, intravenous [IV]
vasopressors, surgery, blood
products, antibiotics)
Prognosis and
trajectory of illness
Approach and
commitment to
controlling symptoms
Disposition and discharge
options, to include home,
hospice care,
hospitalization, initiation of
critical care
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
38. G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
3. Elicit patient values. Engage the patient or
surrogate with open-ended questions:
"What is most important to you in your (or your
loved one's) life right now?"
"What kind of results are you hoping for?"
"What do you hope to avoid at all costs?"
If appropriate: "Have you been with someone
who had a particularly good death or a
particularly bad death? Tell me about it."
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
39. G u i d e F o r A n
E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n
T h e E D
4. Use appropriate language.
•Avoid negative statements, such
as: "Do you want us to withhold
aggressive treatment?"
•Frame the discussion positively:
•"We want to ensure that you receive
the kind of treatment you want."
•"Let us discuss how we can work
towards your wish to..." (e.g., stay at
home).
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
40. G u i d e F o r A n E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n T h e E D
5. Reconcile the goals of care.
Sometimes a "time-limited trial" of therapy is needed to help the patient and family
cope with circumstances or reach a consensus about goals. If so:
• Outline the proposed treatment plan clearly.
• State the goals that you are hoping to achieve with the plan.
• Clarify how you will determine that these goals are being met.
• Establish a period of time for determining if the intervention works and is consistent with
goals of care.
Clinicians may need to set limits on unrealistic goals without making the patient feel
abandoned: "I understand your goal is not to be a burden to your family and you want
an assisted death. Unfortunately, I cannot do that. However, I can help you manage
distressing symptoms, and I can find ways to help you not be a burden."
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
41. When decisions are made about
initiation of life-sustaining
interventions, it is often helpful
to present treatment options as
time-limited trials to see if they
will meet the care goals; if they
do not, this may set the stage
for possible withdrawal later
when they no longer meet the
patient’s care goals.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
42. Another productive tactic is to
portray life-sustaining
treatments as “bridges to
recovery,” thus implying that
life-sustaining treatment is not
intended to be indefinite therapy
and is only appropriate when the
patient has the potential for
recovery at some future time.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
43. G u i d e F o r
A n
E f f i c i e n t
D i s c u s s i o
n O f G o a l s
O f C a r e I n
T h e E D
6. Recommend a care plan based on the patient's goals.
a. Summarize the patient goal (e.g., "From what I
understand, your goal is to...")
b. Outline the plan (e.g., "In order to meet this goal,
we can...")
c. Be specific whenever possible ("I would/would not
recommend...")
•Discuss discontinuing interventions and therapies that
will not help meet the patient's goals.
•Diagnostic, treatment, and disposition plans are best
formulated and discussed with the patient's goals of
care in mind.
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
44. M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s
T o T h e E D
45. M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o
P r e s e n t s T o T h e E D
46. M a n a g i n g T h e p a l l i a t i v e c a r e P a t i e n t
W h o P r e s e n t s T o T h e E D
47. M a n a g i n g T h e p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s T o T h e E D
48. M a n a g i n g T h e p a l l i a t i v e
c a r e P a t i e n t W h o
P r e s e n t s T o T h e E D
49. “There is nothing more that can be
done” does not exist in the lexicon
of palliative medicine.”
We do not abandon dying patients
and their families.
W e c o n t i n u e t o
p r o v i d e
c o m p a s s i o n a t e
c a r e e v e n w h e n
c u r e i s n o
l o n g e r p o s s i b l e
50. 1) To see the patient & the family through
the physical & emotional stages of terminal illness
2) To ease their burden along the way
to walk alongside, not to give orders from above
3) To be there
when symptoms arise, when hard questions
have to be faced, when fear & loneliness threaten
T A S K S O F T H E
M U L T I D I S C I P L I N A R Y C A R E
T E A M
51. T A S K S O F T H E
M U L T I D I S C I P L I N A R Y
C A R E T E A M
To apply to the care of
the seriously-ill,
the terminally-ill, and
the dying
the same high standards of clinical
analysis & decision-making as are
demanded in the care of patients
expected to get well