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Dying on arrival… April 25, 2013

Posted by Andy Jagoda, MD in : Psychiatric and Social Emergencies, Respiratory Emergencies , trackback

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. As the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation are clearly inappropriate? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of .hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you are doing the right thing.

What other medical strategies exist to help this distressed, symptomatic patient?

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Comments»

1. Matt Frankel - May 1, 2013

I would find out if the husband had Power of attorney. If so I would talk to him. If not IO would ask the patient what she wanted. I would offer pallaitive care if desired. They would know I would not expect the patient to survive long. I would assure them of comfort. I also would explain that the pain medicine may casue apnea, hastening her demise. I would the choice up to the patient and/or POA.

2. Roxanaghanaie - May 1, 2013

Hi. I would intubate her with tranquilizer to minimize her suffering but maintain the airway. Patient preference is important too

3. phil Leavy, MD - May 1, 2013

she’s prepared to go to hospice, husband clearly is aware of DNR meaning, just clarify this topic for him, hav him or her sign papers refusing intubation and invasive care, then give her morphine
get xray to r/o treatable problems-like pneumo

4. E.S. - May 1, 2013

Bedside US to evaluate for cardiac tamponade/large pericardial effusion, PE with right heart strain and/or large pleural effusion.

5. David Williams - May 1, 2013

I’d quickly outline care that’s available from intubation to bipap which is an appropiate option as it’s noninvasive.
A decision would also inbclude her husband’s wishesn at that point realizing that heroic measures would potentially prolong life and suffering.

6. Jennifer Bennett - May 1, 2013

Consider CPAP, small dose morphine, solumedrol, duoneb, portable chest X-ray (to evaluate fluid status, also mass effect of cancer?). Attempt to stabilize patient to have a conversation with the patient and husband. If either are equivocal, and patient without improvement- RSI/intubate. Stabilize patient. Contact primary/oncology physician. You can intubate now and talk later. Decision making after the patient is dead isn’t useful.

7. Gabriella Garofalo, MD - May 1, 2013

lorazepam 2mg IV initial then continuous infusion 0.01-0.1mg/kg/hr to maintain reasonable level of sedation.

8. Negean Vand - May 1, 2013

You can use NIPPV such as BiPAP along with some morphine and even some ativan to help make her comfortable. Once that is done initially, I would have a more in depth discussion with her husband regarding goals of care and making the patient comfortable. Many hospitals have on-call palliative care or hospice that can come in or at least discuss the case over the phone which could be an option.

If there are concerns regarding legal ramifications, there is always the option of calling the hospitals legal consultant. It seems in this case they have already been somewhat prepped regarding end of life care, which may make it easier to start the patient on something like a morphine drip.

9. Ajeet Dube - May 1, 2013

Oxygen, Bipap are noninvasive measures. Lab work/cxr.
Have a discussion with family about the pts. wishes and desires. Goals of care.
Contact pts. oncologist and pcp if they are involved/trusted by the family.
This is an unfortunate situation. Aggressively intubating and/or starting a central line would be inappropriate for this pt.
+/- on antibiotic use with this pt. (if a pneumonia is present).

Developing an Emergency Department protocol in concert with Palliative care in advance for these situations would be proactive and beneficial. In particular to administering morphine for comfort care, we are not well trained in this as EM physicians but must accept it as part of our role in medicine.
Excellent discussion topic.

10. Mark W. Fowler - May 1, 2013

The Differrential diagnosis would have to include Pulmonary emobolism; post obstructive pneumonia, and pneumothorax. A chest Xray or CT PE protocol or VQ scan would confirm the diagnosis. BiPap or Cpap might allebvkiate hypoxia and improve ventilation. Morphine certainly indicated to reliecve distress. Interventional Radiology might be able to helop with Thrombolytics

11. hasan - May 1, 2013

this patient reach to the end stage of her disease . the best for her is to let her go in peace with less Agony , with re breathing mask with high flow oxygen , fluids and morphine . same time explain to the husband how bad is she and her suffering and every thing for management of her cancer was done .

12. john garr - May 1, 2013

Cpap, bipap, morphine

13. David Ghilarducci - May 1, 2013

1.Discuss any advanced directives with husband

2. Offer CPAP if no advanced directives

3. Discuss goals if therapy. What is important to patient and husband? Comfort, time to say goodbye, return home when better etc??

14. John Ella - May 1, 2013

It would be appropriate to find out if the patient has an advanced care directive re end of life/palliative care issues. If not it would be appropriate to obtain whatever information was available re the patient’s treatment and prognosis to date. I t would also be important to discuss NFR orders if not already attended. The patient and her partner need to understand the limitations of what is possible and appropriate given the seemingly poor prognosis. I would the patient’s partner if any family were to be called. I would also involve the on call Social worker to help with all of the social /family needs.

The patient requires oxygen and assistance with work of breathing. As rapid sequence induction and intubation are not suitable options I would try Bipap to reduce the patients work of breathing, however this is a temporising treatment aimed at short term symptomatic relief- this would need to be explained to the patient and her partner. I would also administer a small dose of a sedative such as Midazolam and a narcotic such as Morphine or Fentanyl to alleviate the patient’s distress. If possible I would try to arrange a private or palliative room for ongoing care.

15. Eric Brantley - May 2, 2013

Bipap

16. emily keel - May 2, 2013

bipap until discussion with husband about morphine.

17. Mark D. Cousineau, MD, FACEP - May 2, 2013

This patient is dying of terminal lung cancer and she and her husband were in the process of setting up hospice. It is actually more unethical to deny them that choice. There is a difference b/w hastening someone’s death and making someone comfortable. Small aliquots of morphine is appropriate along with other treatments such as abx for suspected pneumonia, lovenox for suspected P.E., etc. as DNR does not mean Do Not Treat. Not treating pain is a big problem for ER doctors already. This case requires making both patient and her husband comfortable and realizing helping someone die peacefully and painlessly is as much a part of our job as emergency airway management.

18. Harold Mayeri - May 2, 2013

HBO to increase O2 levels through plasma concentration
corticosteroids to increase appetit ecombined with high caloric foods to attempt to reverse effects of cachechsis
Medical marijuana p.o.where available to initiate palliative care

19. john harrison - May 2, 2013

BiPAP is non invasive and could be considered to help relieve symptoms. Anxiolytics in low dose may also be of benefit. High flow nasal oxygen could be employed as well. Most important may be discussion with spouse and pt, in the presence of a nurse, what they want done. Document the fire out of it and do the right thing for the pt.

20. Mike - May 2, 2013

Judicious use of morphine is first step. DNR does not mean do not treat. Provide supplemental oxygen treat fever

21. khalil s - May 2, 2013

only. IV in countinuios infusion with morphin. no endotraceal intubation or other invasiv manipolation. May-be some idration.

22. FREDA lOZANOFF,do - May 2, 2013

Agitation kills faster. Death should be peaceful. I would give this patient sedation with a benzo or morphine,and start with nasal O2.
If they have selected hospice care, I wouldn’t intubate at this time. I would then discuss with the spouse any end of life wishes expressed.

23. Dr SureshNaidu - May 3, 2013

i will consider what the patient would have wanted in the circumstances and what do the husband want. in this case patient already has choosen not to continue chemo and opted for hospice.i would explain the prognosis to the husband. i might consider non invasive ventilation, in an unlikely event that it might work. After explaining to the husband, the prognosis , and would suggest to him the option to provide the best possible tender loving care which my resources allow. i might start her on sedation/analgesic. i would not consider endotracheal intubation and ventilation in this patient

24. nsb - May 3, 2013

confirm the DNR DNI status with next of kin and chart review, then IV ketamine and look for treatable causes like pneumonia

25. Margaret Marcinik, DO - May 3, 2013

1. The pt is clearly agitated and hypoxic — pulling the NRB off her face. She has already decided that she would enter a hospice program per her husband. I would start an IV, continue oxygen and place her on CPAP temporarily. I would give her some IVF and a small dose of haldol to give one time to talk to the pt’s husband about her/their wishes. The pt is clearly not able to hold conversation upon arrival. It is doubtful that with any meaures that she would be able to make a concrete decision about her care at this time.
2.Talk to the pt and her husband. The goal is to make the pt comfortable (oxygen, IVF and haldol) and not prolong her life. I would not do studies to find causes for her symptoms.
**Once her agitation is controlled one may attempt to discontinue the CPAP and to titrate oxygen to keep her comfortable.

26. brijesh parikh - May 3, 2013

I would give oxygen + non-invasive ventilation(bi-pap),to start with,analgesics to the patient to relieve the pain,vasopressorsto improve the bp, fluid bolus only if she is not in failure and talk to
the husband and formulate an approach inclusive of the husband’s decision, while the labs, and x rays are available.

27. Michael D. Alch, M.D. - May 3, 2013

Our journey towards our end is often fraught with fear. Providing the means to manage pain, agitation, respiratory secretions, nausea and vomiting, and dyspnea can ease that path, and restore patient dignity.
Emergency physicians are wise to recognize the trajectory of their patient’s illness, and place the patient properly in that trajectory. In this case, their caregivers have guided the patient and her husband to hospice, having completed unsuccessful attempts at chemotherapy. Our impulse is always to intervene dramatically, restore the airway, diagnose the threat, and aggressively treat it. In hospice, this patient would receive sedation and analgesia.
Questions about power of attorney, and advanced directives are for another day, as are ET tubes, BIPAP, and Lovenox. A warm and loving approach, and confirming that she is approaching the end of her struggle is enough. Your choice of hospice, I would say, tells me that you do not wish further medical treatment. When the patient and husband confirm this, the offer to provide medicine that will ease her distress is usually gratefully accepted. I will take the family away from the bedside to prepare them for the inevitable, and let them know that making her more comfortable may also decrease her respiratory drive. Death, hopefully without undue suffering, I explain, could follow rapidly.
Then, as the medicines are given, the family and I are at the bedside with the patient. While the RN has gone to get the ordered meds, I will have written my DNR/DNI, and spoken with the nurses, so that we are all at one with the goal of this end-of-life therapy.
Ira Byock, MD, is Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. His approach is this: Palliative care does whatever is necessary to eliminate the suffering. Euthanasia is focused on eliminating the sufferer. Therein lies the critical difference. Treat your patients as you would want your own family treated, confirm that choice, and you will seldom be wrong.

28. Henry Richter MD - May 4, 2013

this is straitforward end of life care. A living will/DNR makes it easy, a little morphine/ativan and holding the husband’s hand.
Without a DNR, explain you will do exactly what he wants , make her comfortable, give the morphine and ativan, arrange for hospice care if she is still living , comfortably sedated and relaxed.
I would not even consider anything invasive. no labs , no pulse ox device, mo monitor.

29. Ettie Wells - May 4, 2013

First I’d find out if the patient is oriented and able to make a decision about her own care. If yes, I would follow her wishes. If not, I’d follow the husband’s wishes. When immediate action is needed I find it unethical to dig into legal issues about POA, etc. If they wish comfort care only I’d make her as comfortable as possible – they obviously know the patient will die soon. If they want aggressive measures I’d do my best to explain the futility, dangers and discomfort that would cause and again, I’d try to make her as comfortable as possible.

30. TAREK BEDAIR - May 5, 2013

no intubation for DNR patient, only supportive measures

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