The rapid code status conversation guide for seriously ill older adults in acute respiratory failure

rapid code status

You are working a regular shift in your emergency department (ED) when a 85 year old female presents with a complaint of altered mental status. She comes from an extended care facility, where paramedics are able to tell you “they called us to come get her”, you are handed a stack of paperwork, given some vital signs and you notice the patient is altered beyond being helpful to you. You dig a little in the paperwork and note a history of dementia, as well as a long list of other medical problems, you notice no known advanced directive and a number to speak with her daughter who lives out of state. Have you been here? Seen this patient? IF you have work in emergency medicine long enough you certainly have. The tool outlined below is designed to help you know what to do in these difficult situations.

Emergency physicians are responsible for setting the trajectory of hospitalization for seriously ill (terminal illness with less than one-year prognosis) older adults [1]. 75% of older adults (≥65 years) visit the ED in the last six months of life [2]. More than half of such patients lack advance directives [3]. Emergency physicians are tasked with completing the hardest conversations in medicine – helping patients determine their goals-of-care and making rapid decisions regarding the use of life-sustaining therapies. The importance of this task has been amplified during the COVID-19 pandemic. Emergency physicians must recognize that the best possible outcome after survival may be “worse than death” for seriously ill older adults. One in three older adults die in the hospital after intubation, and most survivors would go to places other than home with limited life-expectancy. Among decedents, the mean time to death is three days. These overall survival characteristics are influenced by age (e.g., 50% in-hospital mortality for those above age 90) and comorbid conditions (e.g., 40% increased odds of death for those with Charleson Comorbidity Index >4) [1].

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By |2020-05-22T20:54:46-07:00May 25, 2020|Palliative Care|

Work Grief: A Primer for Emergency Medicine Providers

griefHeartbreaking patient situations are the backbone of Emergency Medicine. Whether it’s a new cancer diagnosis, telling a family member that their loved one has died, or the creeping dread that a mistake that we’ve made will negatively impact one of our patients, we all experience extraordinary stress in our day-to-day clinical practice. Most clinicians are not tasked with routinely sharing news about the violent, unexpected, and horrific life-changing situations that occur in the emergency department, and yet we are given so few tools to help us manage this firehose of grief. This article is intended to share some of the best practices of grief management with clinicians who are immersed in grief, even if unawares.

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By |2020-05-22T12:34:22-07:00May 22, 2020|Palliative Care, Wellness|

What is palliative emergency medicine and why now?

elder hand palliative emergency medicine care

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.

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By |2019-07-23T00:34:41-07:00Jul 31, 2019|Geriatrics, Palliative Care|

Beyond the Abstract: Patient video testimonials improve physician interpretation of advance directives and POLST

advance directives and POLST with videoOver 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?

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