Emergency Department Management of Dyspnea in the Dying Patient (Pharmacology CME) -
Publication Date: July 2018 (Volume 20, Number 7)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 7/1/2021
Specialty CME Credits:: Included as part of the 4 credits, this CME activity is eligible for 2 Ethics CME, 2 Palliative Care CME, 2 End-of-Life Care CME, and 1 Pharmacology CME credits, subject to your state and institutional approval.
Ashley Shreves, MD
Emergency Physician, Ochsner Medical Center, New Orleans, LA
Trevor R. Pour, MD
Assistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Ethan Cowan, MD, MS
Associate Professor of Clinical Emergency Medicine, Icahn School of Medicine at Mount Sinai; Mount Sinai Beth Israel, New York, NY
Michael Turchiano, MD
Attending Physician, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
Dyspnea is one of the most distressing symptoms experienced by dying patients, and it is a common reason for such patients to seek care in the emergency department. Many underlying disease states and acute illnesses cause shortness of breath at the end of life, and management tends to be symptomatic rather than diagnostic, particularly in those for whom comfort is the most important goal. Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and hand-held fans may also be used. Benzodiazepines may also be helpful in select patients. The early involvement of palliative medicine specialists and/or hospice services for dying patients can facilitate optimal symptom management and transitions of care.
Excerpt From This Issue
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. When 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 seem inappropriate, but what other medical strategies exist to help this distressed, symptomatic patient? 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 do the right thing.
Nagla A, MD - 09/07/2018 After reading this, I will initiate opioids for dyspnea early on in the care of the dying patient and not just for pain relief. I will use NIPPV as an option for dyspnea for hospice patients.
Jacob C., MD - 09/04/2018 I'll make several changes to my practice as a result of this article: improved end of life care in the emergency department; improved efforts with communication and POLST identification; improved symptom care for the dyspnic patient in the ED.
Deborah F. F, PA-C - 09/03/2018 Great clinical pathway!
- 08/09/2018 This article was a long time coming regardless of state CME requirements. In residency we learned how to sensitively convey the death of a patient but never really focused on the dying process. I'm embarrassed to say in 25 years of practice i never thought to ask "What's most important [to you]?" It's also a reminder of what the pre-hospital people face with limited information. Excellent review. Should be required reading.
- 07/30/2018 One of the most engaging and sincere CMEs I've ever done. Very eye opening to what we are actually here for and the need to align our goals with the patients and family. Please let the authors know great job and they are making a difference.
Charles N., MD - 07/27/2018 This course was an eye opener... never thought about palliative care before... and opiates for SOB seemed counterintuitive.. thanks!
Jill S., MD - 07/26/2018 I will now have better communication with family regarding patient wishes
William M. - 07/25/2018 This issue discussed an important and increasingly prevalent clinical problem which is not often well handled in the ED. The knowledge presented will help clinicians provide better care to these distressed (and distressing) patients.
D. S., MD - 07/23/2018 I will approach the dying patient with more confidence that I can support them appropriately with judicious interventions that will make them more comfortable while not prolonging their suffering.
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