- If medical care is futile, emergency physicians (EPs) should “transition to comfort care.”
- Aggressively managing symptoms, minimizing disturbances, and not abandoning patient and surrogates are crucial to compassionate care for dying.
Why this matters
- ED physicians should discuss comfort care “when ED care approximates futility, either imminently or in anticipated downstream hospital course,” authors say.
- Systematic review of literature on symptom palliation, care coordination for acutely dying patients.
- Grieving starts before death; ED staff can influence family’s experience.
- Advanced directive can begin conversations.
- Consult risk management if surrogate-document conflict arises.
- “Transition to (aggressive) comfort care” is preferred phrasing over “withdrawal of care.”
- “There is nothing more that can be done” is never true; patients and surrogate suffering can be eased.
- Prognostic signs: sagging jaw, pulselessness, Cheyne-Stokes respirations, apneic pauses.
- Symptom management:
- Pain, dyspnea: bolus opioids; reassess; benzodiazepines are second-line for dyspnea;
- In awake patients losing airway, sedate to unconsciousness;
- Terminal delirium: benzodiazepines, antipsychotics;
- Secretions: anticholinergics.
- Before extubation, stop pressors, fluids, mechanical circulatory support; deactivate cardiac devices; bolus comfort medications, especially if patient triggers breaths, has cough, gag.
- Involve nurse, respiratory therapist, social worker, chaplain.
- Stop monitors, alarms; allow visitors; minimize disturbances.
- Periodic reassessment mitigates feelings of abandonment.