Last weekend my residency program had a winter retreat. It was a smashing weekend. In addition to enjoying the excellent company, tobogganing, cross-country skiing, and Baileys-infused Tassimo coffee, we also learned a lot. Our guest speaker was Dr. Leneela Sharma, an emergency physician practicing in Edmonton, Alberta that has additional training in palliative care.
In retrospect, I recognize that my education on palliative care is extremely lacking. I never rotated through a palliative rotation in medical school and this was the first lecture on the subject that I had in residency. I thought the FOAM literature (FOAMiture?) was similarly scant, with an EMgoogle search of “palliative care” identifying a “short snippet” summary of an article in February of 2012 on LITFL, several reflective pieces like these ones by torontoemerg blog and storytellERdoc, and a reasonable amount of traditionally published literature. However, following the posting of this blog I was directed to several other palliative care resources and a big one that I (embarrassingly) missed completely by Scott Weingart on EMCrit (I clearly need to spend more time on my FOAM pre-search: huge apologies). Also, a keen medical student (who tweets from @Want2beMD and blogs here) directed me to a great discussion of DNR orders on the Canadian radio show White Coat Black Art and Chris Nickson linked me to the extensive GeriPal blog by @GeriPalBlog. (Please let me know if I missed anything else so I can add and learn from it!)
With many thanks to Dr. Sharma who encouraged us to disseminate her teaching in any way we can, I will be borrowing heavily from her presentation to work through her 4 step approach to the palliative patient in the ED. But first: what is palliative care and why does it matter in the ED?
Dr. Sharma defined it as “the prevention and relief of suffering.” This is much broader of a definition than I would have provided if asked prior to the talk, but following her presentation, I can see how well it fits.
Obviously, because if our patients will suffer / are suffering, we want to be able to relieve it. Dr. Sharma went on to define the primary skills of palliative care in the ED as managing pain and symptoms, delivering bad news, and helping families to make difficult decisions. Three things that we do on a daily basis and could likely improve upon with increased focus.
If they are unstable, determine if they have an advance care directive that specifies their wishes regarding resuscitation and provide care in accordance with it. This is standard emergency practice that we do not have trouble with. Things get more complicated when they are stable. In that case, besides doing the regular history and physical exam, we need to work through the ABCD’s of palliative care.
If they are stable/stabilized, assess the following in addition to the usual history and physical exam:
Acquire it if it is not with the patient. Review it to get a good understanding of the patient’s wishes. If possible, review it with the patient to ensure that their wishes have not changed.
Make the patient feel better! Re-hydration, pain control, antiemetics, etc.
Determine who they are, where they are at with caring for the patient and how they are coping at home.
Determine if the patient is still able to make their own decisions regarding their care. If not, get in contact with whoever is responsible for decisions.
The disease trajectowhat? Again, perhaps it is just me, but the explicit discussion of disease trajectories and the idea that they can be labelled on our charts had evaded my medical education prior to this. As it turns out, there are four well described disease trajectories. They are well described in this freely available 2003 JAMA article that also provided this depiction:
I don’t think this one needs much explanation for those working in emergency medicine. This is the trajectory that previously healthy folks take when they suddenly develop fatal pathology.
Cancer fits this trajectory. It is expected that the patient will have a prolonged illness while generally maintaining their function until near the end when function sharply drops off.
Most often referring to cardiac and respiratory failure, the trajectory of organ failure involves a relatively steep decline with intermittent exacerbations. They ultimately die during one of these exacerbations and, when they survive, they never reach their prior level of function.
These are the elderly folks that never develop any severe illness but slowly decline in function and ultimately die from a complication of their progressive disability.
Based on a knowledge of disease trajectories, the notes of the consulting physicians, and the patient’s current level of function, it should be possible to formulate a reasonable prognosis. This can be done qualitatively (curable vs non-curable) or quantitatively (length of time).
I noted that I often shy away from committing on this point unless the patient or their chart spell it out for us. I suspect that many of my fellow EM residents +/- consultants do act similarly. This may be the result of a lack of knowledge of prognostic markers, the short-term nature of the care that we provide, or a lack of teaching on this aspect of care. Efforts such as the development of the EPEC-EM curriculum (Dr. Sharma’s primary resource) have been made to close this knowledge gap, but I think it still exists. This is unfortunate, as Dr. Sharma demonstrated the importance of the prognosis in considering interventions and formulating the goals of care.
For a patient that is expected to have only days to live the goals of care might be to provide comfort with interventions such as pain control and getting the family to the bedside.
For a patient that is expected to have weeks to live, some patients may prioritize quality of life over duration. These patients might prefer going home with comfort measures to being admitted for an invasive workup and/or treatment.
With the prognosis stated clearly, the goals of care and interventions to consider follow much more clearly. Of course, the goals of care and potential interventions should be discussed openly with the patient and/or their family as they will differ between patients with similar prognoses based on their values. However, if we are unsure of the prognosis or hesitant to label it, these discussions are not held at the same depth and we may end up recommending interventions that the patient may not have otherwise chosen.
This review provided an excellent overview of physician views on prognostication. One important pearl it mentioned is the importance of explicitly prefacing any discussion of prognosis with the acknowledgement that we can’t predict how an individual will respond to an illness or its treatment.
Dr. Sharma had two great pearls to assist in prognostication. She recommended asking the patient:
“Is your cancer curable?”
While this question is obviously only be applicable to cancer patients, I find it striking in its simplicity and effectiveness. In four short words, it invites the patient to tell us their understanding of their prognosis as well as subtly opening the door to allow them to share their hopes about it. Have they been told that their illness is terminal? Do they have a timeline? And what are their goals?
“How much time do you spend in bed?”
Dr. Sharma told us that the most important prognostic factor is functional ability and this question is an excellent way to measure it. She stated that if 50% or more of a patient’s time is spent in bed their median survival is approximately 3 months. As seen in the terminal illness trajectory, the development of significant symptoms and functional impairment places them on the steep part of the curve. I looked for a specific reference for this information, but could not find one. When asked, Dr. Sharma noted that this is a rule of thumb based on various prognostic tools that she has studied and references included in the EMEC-EM curriculum. She recommended the Karnofsky Performance Status as a tool to quantify the functional ability of palliative patients more objectively. While the prognostic value of this question should be considered expert opinion until further evidence (perhaps from this study) is published, it seems like a great way to inquire about functional status.
While I expect that prognostic knowledge and comfort with speaking to patients about prognosis will develop with clinical experience, it will be of no use if we do not offer patients the knowledge that we do have.
A palliative patient’s care plan should be consistent with their presenting problem, disease trajectory and prognosis. It may be drastically different than the care provided to a non-palliative patient and will depend on their goals of care. Dr. Sharma classified goals as cure, providing comfort, prolonging life and preventing complications and noted that they may shift over time.
Dr. Sharma illustrated the concepts that she discussed by posing the case of a hypothetical patient with lung cancer that presented to the ED with progressive SOB multiple times worried that she had developed a PE. At her previous visits she had been sent for CTPA’s that did not show emboli. After working through these steps, it was evident that the patient knew that her cancer was terminal and accepted that she only had weeks to live, but was hoping to live out her last days at home. She continually presented because she was worried that her worsening SOB was due to a PE that could further shorten the brief period of time that she had left. Rather than order another CT, treatment with outpatient LMWH injections was arranged to prophylactically treat any clots and alleviate her anxiety.
Was this standard of care for PE workup and treatment? No. But it made sense in the context of this patient who understood she was at the end of her disease trajectory and presented with the goal of prolonging her quality of life at home for as long as she could by preventing a PE. At earlier presentations, her goals of care would have been cure and an extensive workup +/- hospital admission would have been as appropriate for her as any other patient.
I found Dr. Sharma’s presentation to be enlightening and think that all emergency physicians should develop a formal approach to seeing palliative patients. While using an approach like this may take more time up front, the above example illustrates the potential results: improved patient and family satisfaction, more appropriate care, decreased resource utilization, and, likely, improved physician satisfaction. Dr. Sharma deserves a huge thank you for traveling 8 hours to speak to us on our retreat and reviewing this post.
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