Northeast Florida Medicine, Spring 2016

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DCMS online. org Northeast Florida Medicine Vol. 67, No. 1 2016 15
Palliative Care
Introduction
As the specialty of palliative care evolves, it is becoming
apparent that its presence is now more far reaching in
all spectrums of disease and specialties. Palliative care
physicians can influence the education of both patients
and providers to improve quality of life at any stage of
illness. This is of particular importance in emergency
departments as they often have initial contact with
patients, especially those with uncontrolled symptoms.
It has been shown that in the last six months of life 40
percent of advanced illness patients present to the emer-
gency department (ED).1 The number of visits increase
closer to the last few months of life; 75 percent in the
last three months. Of these, 77 percent of patients are
admitted and 68 percent eventually die in the acute
care setting.1 These admissions are burdensome, costly
financially to both the patient and institution, and, per-
haps most importantly, they can have a negative impact
on quality of life measures. Programs that successfully
amalgamate palliative care (PC) in the ED are at centers
with inpatient PC teams. Fortunately, in Duval County
most facilities have this vital inpatient resource.
Emergency Department
Emergency department physicians (EDPs) are dis-
position driven and work in a high pressure, acute
environment while simultaneously managing multiple
patients with advanced disease. If a patient’s disposition
is not altered by immediate management it is typically
addressed secondarily. Any successful palliative inter-
vention in the ED must be efficient, beneficial, and
purposeful. Additionally, rather than assume the patient
is presenting for lifeprolonging/saving care, EDPs should
address patient goals andembracedifficult conversations,
as these outcomes can impact future trajectories of care.
An emergency physician mantra is often “Does it need
to happen in the ED?” Merging primary palliative care
principles with the emergency culture should therefore
expand the mantra to “What can happen in the ED?”
Literature indicates that primary visits to the ED in
the palliative population are typically related to poorly
controlled symptoms.1,2
Pain Management
When patients present to the EDwith pain complaints,
it should first be determined if this represents a new and
changing process or an uncontrolled chronic pain emer-
gency.Given the pharmacokinetics of opioids, intravenous
therapy (IV) medications should be used when treating an
acute pain crisis in the ED. IV formulations generally peak
in 10-15 minutes, as compared to 60-90 minutes for oral
administration. Additionally, it is vital to be familiar with
simpleopioidequianalgesicdosing(Table1)forappropriate
conversions. Otherwise the risk of over/under dosing is of
concern.3 An empathetic conversation communicating
expectations should be undertaken to agree that the goal
may be for pain relief rather than complete resolution,
especially in the opioid tolerant patient.
Address correspondence to:
Andrea C. Sharp
Mayo Clinic
4500 San Pablo Road
Jacksonville, FL 32226
904-953-1498
Palliative Care in the Emergency Department:
What Can Happen?
By Andrea Sharp, MD
Abstract: Emergency departments often have initial contact with
palliative care patients; especially those with uncontrolled symptoms
and those who are nearing the end of life. Not all palliative patients
presenting to the emergency department are seeking lifesaving or
prolonging measures. Common reasons for visits include uncontrolled
pain, dyspnea, nausea/vomiting and constipation. Most of these pa-
tients will presumably have the “standard of care” treatments already
in place. There are escalating treatment alternatives for the acute care
setting that adhere to primary palliative care principles.