Dying patients in the ED: best practices for providing comfort care

Access to the full content of this site is available only to registered healthcare professionals. Access to the full content of this site is available only to registered healthcare professionals.

Takeaway

  • 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.

Description

  • Systematic review of literature on symptom palliation, care coordination for acutely dying patients.

Key details

  • 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.