The skilled and rapid resuscitation of critically ill patients is a central premise in the specialty of emergency medicine (EM). A paradox for providers often arises when in the midst of resuscitating a patient with advanced chronic illness, the question of risks versus benefits arises. For this patient, we may successfully stabilize vital signs, but at what cost? Will this patient return to a quality of life they deem acceptable? What are the patient’s goals of treatments given his/her underlying disease? These questions illustrate the need for emergency physicians to be more aware of and comfortable with palliative care practices.(more…)
Beyond the Abstract: Patient video testimonials improve physician interpretation of advance directives and POLST
Over 1,300 physicians across the U.S. were asked to interpret patient preferences for end-of-life care in theoretical cases. Physicians rarely reached consensus about patient preferences when they were given only living wills and POLST documents to interpret. The addition of a patient video testimonial helped physicians make better care decisions that reflected their patients’ wishes. Will video become the new national standard for advance care planning?
Pain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients.1 There is evidence that older adults are less likely to receive pain medication in the ED.2,3 The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.
Older adults are at high risk of poor outcomes from even minor head injuries. We see many older patients in the ED who present after a fall or head injury, and we have good decision rules for which patients need brain imaging.1 However, even patients with mild traumatic brain injuries, who have a negative CT scan, are at risk for mortality and significant long-term sequelae. The CDC has called traumatic brain injuries a ‘silent epidemic’.2,3 The first steps to breaking that silence are awareness and recognition.
Hip fractures are an important cause of morbidity and mortality in older adults. The average age for hip fractures in the U.S. is 80 years, and a staggering 20% of women and 10% of men 1 will experience a hip fracture in their lifetime if they live to older age. This makes it a costly injury, racking up close to $15 billion per year in the U.S. alone. 2 Some hip fractures are obvious as soon as the patient rolls through the ambulance bay. Others can be subtle and require more than just a plain X-ray. This post will discuss risk factors for hip fractures, and how to diagnose and manage patients with hip fractures in the ED.
What is Palliative Care? It is specialized medical care focusing on improving the care and quality of life for patients with advanced illness by decreasing suffering. It can be delivered concurrently with curative care. Early identification of patients who are likely to benefit is key. How do you decide whether your patient could benefit from a palliative care consult?
Every day in the Emergency Department we see older adults with dementia who have developed delirium and are brought in because of worsening agitation, combativeness, or confusion. In order to care for them, we have to consider what the underlying cause of their agitation may be, but we also have to protect the patient and staff in case of violent outbursts. Older adults experience a phenomenon termed ‘homeostenosis’ in which their physiologic reserve and the degree to which they can compensate for stressors is narrowed, putting them at risk for delirium. This post will outline ways to prevent and de-escalate agitation in a patient with delirium, and how to treat it pharmacologically in a cautious manner to minimize side effects.