Summary
We hope you have added to your knowledge skills and attitudes about End-of-Life care and Symptom Management in the Older ED Patient. Caring for patients at or nearing the end of life is a challenge in the ED. A busy chaotic environment is a difficult place to have sensitive discussions about life’s most important issues! Our ability to provide excellent care to vulnerable patients and families can be increased by using our knowledge of disease trajectories and prognosis. Patient care can be improved by moving beyond “do you want to be resuscitated” to a more complex discussion of goals of care. And we can practice so that we can be the doctor we would want to have if we were in pain.
As part of your regular practice, it is important to encourage patients to have the discussion with their family or substitute decision maker about their values as it relates to their goals of care. In addition to this allowing for the patient’s wishes to be known and respected, substitute decision makers may feel less conflicted when trying to determine what their loved ones would want as they near the end of their life.
You may also want to review the modules on Medication Management and Functional Assessment which have specific relevance to this topic.
Review the Learning Objectives before proceeding to the Knowledge Check.
At the end of this module the learner should be able to:
- Describe disease trajectories, recognizing their link to prognosis and end-of-life decision making.
- Use disease trajectories to inform discussion of goals of care and advance care planning in the ED.
- Name the key components of an effective goals of care discussion.
- Describe ED-appropriate management for pain, nausea, constipation, dyspnea, and anxiety.
Discussion: Summary
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Will be more consistent with MEDD calculation and increase in your dose
Reconocer el paciente terminal, mayor comprensión con la familia. Un manejo adecuado del dolor y calidad de vida en la fases terminales
finding a private room to sit down with patient/family/representatives and have a clear, detailed, empathetic discussion about goals of care
identify proxies early, discuss goals, involve family when appropriate
end of life care principles and strategies
keep people comfortable, respect their dignity and wishes. No reason for people to suffer terribly.
clear discussion
MEDD
To be clear and give the information patients need
The different ways of palliative care and hospice, what is important about the patient in their last times before death.
Increased comfort with opioid conversion, increased comfort with addressing uncomfortable topics in the ER.
Being comfortable discussing goals of care and end of life decisions with patients and relatives. Using prognostic tools
aa
getting comfortable discussing with goals of care and establishing a prognosis in he ED
m
This session was also helpful re opioid dosing.
I think it was important to see that sharing disease trajectory and life expectancies can be an important part of the discussion as an ED physician. And I will try to have more frank discussions in the ED.
Disease trajectories
About meds and their effects
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end of life care in very complex and you need the help of other people to ensure that you are making the right decision
the disease trajectories. Useful framework for discussing disease course with patients.
ok
strategies re GOC discussion
I have learned a lot especially with dealing with anxiety ,constipation ,pain relief in the emergency department I have learned to be mindful of non pharmacological and pharmacological methods to manage delirium in the fast paced ER.I became more knowledgeable about medications and the side effects used in the management of the elderly.I am endowed with knowledge about goals of care and the involvement of the family in the end of life issues and available resources that could help the patient and the caregiver I have learned to recognize apart from physical disease psychiatric ailments of the elderly.I will try to inculcate what I have learnt; to improve the services in the department in the care of the elderly population
ac
More compassionate.
ep
good review of morphine equivalent dosing
Found the portions on GOC discussion and how to start the conversation very helpful
I found the specifics on opioid dosing very helpful. I will feel more comfortable dosing patients based on these guidelines.
Learned a ton of great info. Seriously practice changing!
Good ways to convert various narcotic doses for treatment in ED
helped in strategies for solidifying comfort measures only
yes
First introduction to end of life care really; learned inportant aspects of care and considerations to make.
learned about the aspects of end-of-life care which is important in geriatrics.
g
3
good information
how to word difficult discussions in a better way
How to better manage opioid therapy
ok
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…. 😀
A multidisciplinary approach is needed when dealing with terminal patients
ok
Remember to calculate patient’s MEDD. They may require higher doses of opioids for pain control than I would normally order.
How to frame conversations re: POSTs
Dosing for various symptoms (e.g. pain mgmt)
ok
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As a in any situation
Pomprenhencive approach and use all availabe resourecs taking in account aptien and family needs
complex approach and using all resporces for him and his daughter
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excellent teaching on phrasing for end of life discussions
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Although I’m not a doctor, nor do I work in ED, but it is good to be aware that maybe you are the first person who has spoke with a patient or their relatives about end of life. I have certainly noticed that a number of people seem surprised that their mostly stationery, frail, demented parent of 92 with multiple conditions is nearing the end!
ok
use dopamine antagonists as 1st line anti-emetic in opioid associated nausea
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More comprehensive care for end of life patient.
ok
ok
ok
not too much honestly
good info
EOL care and being ore comfortable with increasing pain medication
learned more about opioid conversion dosing and symptom management in palliative care
I have learned a lot
provide a listening ear as every patient needs are important and quality of life counts regardless of the illness
better approach to patients and their family with poor prognosis
good
ok
ok
Managing end of life issues in the ED
The utility and safety of IV opioid dosing q15min with titration in the ED. PAINAD tool.
ok
I will ask “what is most important to you / your family member in the future as we plan to care for them?”
Also, I will be sure to try to resolve constipation prior to discharge.
how to properly care for the geri population
learned that opiod use can be calculated based on previous use. will be giving more frequent doses for pain control evaluate effectiveness more often
calculation of opioid equivalences
start with maxeran for nausea, adequate pain control by giving iv q15 min until pain controlled
pain meds and palliative care
An important subject, requires multiple disciplines to manage
All super helpful
such an important topic
don’t underestimate caregiver burnout
importance of having end of life care discussions with pt.
learned about prognosis, the importance of goal setting, and comfort measures
Dose conversion very helpful, communication techniques, palliative goal setting
MEDD and symptom review as an important tool
I benefitted from the information regarding opioid equivalents and the formula to calculate breakthrough pain. I feel that we undertreat pain in the ED for fear of respiratory depression and hypotension.
I’ll just generally be thinking more of end of life conversations in the ER and when they are appropriate to have
Aprendí como valorar el enfoque de diagnóstico en el paciente terminal y la interrelación con la familia,además de los problemas más comunes con que llegan a emergencias y cómo tratarlos.asi como los efectos adversos de los medicamentos a usar.
learned about better ways to treat side effects of opioid use
really liked some of the phrasing/suggestions for intervention related conversations
Calculating MEDD for appropriate escalation of pain management
MEDD and conversion of opiates is the most helpful portion
caring for and communicating about end of life care with family members and goals of approach of care
Drugs available for management of different symptoms.
starting the discussion early
must be able to make prognosis and deliver such information to the family, listen to family and use the proper language where applicable. treat symptoms effectively and have a good follow up plan
Palliative care management
goals of care approach
understanding the globel end of life trajections was very helpful
better communication
better ways to discuss about end of life goals and issues, better ways to control pain and comfort in using those doses.
It is important to discuss goals of care with patient and care givers
Good goals of care approach
good module
good way to handle palliative care in ED
Opioid conversion
pain meds
opioid conversion
k
interesting
GPA
pain management is important and medication upon discharge
managing pain is important
end of life care
end of life considerations
end of life caring proces
k
How to initiate the conversation, the importance of being upfront and honest but in a caring way
agreed
patient and family centered care is necessary in palliative care
identify pt is active stages of dying
great eval
symptom management
opioid conversion
opioids conversion
Talk to the patient and family. Don’t assume that the discussion of end of life care has taken place. Ask what their expectations are
how to approach pall.care pt and EOL Pathway
a good history to review symptoms and management. Finding out what the patient and families goal of care is.
so much information.
More focused on goal directed care and better handle on pain control
Focus on goal directed care, improved symptom management in the palliative patient.
I have learned a great deal in this module. The approach to difficult discussions is important and in the past created anxiety on my part. MEDD is something i will use
Role of ED physician in starting the difficult conversations
Palliative docs can be a good resource
figuring MED
not afraid of opiods
how to manage end of life issues
Interesting
Breakthrough pain management dosing in the patient already on opioids (10% of previous daily opioid intake).
When converting between different opioids, reduce total daily dose by 25% as metabolism for different opioids can vary significantly.
better understanding of the four disease trajectories and how they affect care. Also using the Morphine dose equivalent calculation more to provider adequate pain control
Some great tips about how to carry out discussions about end of life care
Good review of pharmacological treatments for the common symptoms
how to approach difficult subjects re advanced directives and EOL care
Recognition of patients who are dying
opiate dosing and conversion were the most useful
Compassionate approach to discussing goals of care and EOL issues. Also the dose conversions were very helpful.
Ok
Encouragement to bring up end of life care with frank discussion; better pain management and understanding of end of life trajectories.
MEDD dosing and symptom management
great information
MEDD
The appropriate way to discuss end-of-life issues with patients and their families as well as symptom management.
Trajectories of death – very useful concept. Strategies for having these difficult conversations with patients.
como abordar en forma integral eventos que no se consideran relevantes pero que lo son y que si no se tratan pueden comprometer la vida del paciente
great information, useful tips
detalles que no tomaba en consideración como el cuidador
yes I agree
very useful information
muy buenos tips
logical approach to follow
frank discussion about the prognosis in order to reach the treatment goals.
I think the part of determining goals of care is very important because ed docs commonly rash to manège the that fracture NOF or that SDH in the elderly patient without taking into consideration background daignosis, disease trajectory, prognosis and without providing ample Info to the carer, and hence not collaboratively coming up with Goals of care and most suitable plan for the patients’ best interest.
I will make sure to determine what the pt./family already know before I start talking. I didn’t know Haldol was used for nausea or that the administration of a glycerin suppository 1 hour before a disimpaction would make the stool softer.
The main thing I take away is specific sensitive approaches to the goals of care discussion. Terms to avoid, terms to use. Give advice.
the module talks about trajetories, but does not actually provide information regarding this
xx
fre
dosage calculations are very important
appropriate jargon to use, treatment of symptoms, followup care, lots of helpful info
The need for goal discussion, treatment planning is there and I will hopefully be more aggressive at making sure it is done before the patient presents to ER.
how to properly manage end of life symptoms so that pt and caregiver benefit
Lots of helpful informations,I added few other useful resources to use in ED.
I like the dose conversion and understanding of what drugs are more appropriate for the elderly population
very helpful resource especially the CCO guide.
i will be sure to access the establishing prognosis tools that is an area i could improve on
I like the right and wrong language approach. the family expects us to take the lead but when you involve them with their goals and that of the patient I think they feel relieved and they are part of the process. Pain relief is always a sticky subject and the module of dose equivalents etc is very useful.
Approprite way of handling palliative care patients in ED.
a methodical review of symptoms their treatment and use of various team members is very important in the care of these vulnerable patients