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On a typically hectic day in the ED at Marlborough (MA) Hospital, several admitted patients were waiting in the hallway for an available bed.
"One of the patients was an elderly woman who had made the decision, after much discussion between the staff, the patient, and her family, that no heroic measures would be taken and no medications other than pain medications would be given," says Kay McClain, RN, MS, CEN, nurse director for emergency services.
When a bed opened up, ED nurses debated over which of the six patients would get it, says McClain. "It essentially came down to two patients. Would it be the one with the most nursing demands or the dying patient?" she recalls. A decision was made that the terminal patient would get the bed, says McClain. "This would give her perhaps a little more peace and dignity during her final hours, even though this might be causing more work for everyone involved," she explains.
This scenario underscores the dramatic impact that you can have on terminally ill patients in your ED, says McClain. "The most important thing that ED nurses can do is realize the important role and unique perspective we have on patients at the end of life," she says. If you don’t comply with the wishes of patients, you face liability risks, warns McClain. "We may find ourselves in trouble for prolonging life when there is documentation that is not what the patient or health care proxy wanted," she says.
Always ask patients and families if they have an advance directive, advises Susan C. Stone, MD, MPH, FACEP, assistant professor of emergency medicine at University of Southern California and Los Angeles County Medical Center. "This is a legal requirement, and it also is the ethical thing to do," she says.
There is a growing trend of EDs treating more terminally ill patients, due to lack of access to primary health care, says Susan Key, RN, MS, CEN, director of emergency services at Cape Canaveral Hospital in Cocoa Beach, FL. "More and more, we are seeing terminal patients ending up in ED for end-of-life care," she says. "This is a completely different mindset for ED nurses, so we need to change our thought processes to meet their needs."
To significantly improve care of dying patients, do the following:
• Manage pain appropriately. You may be inadequately treating pain in terminal patients due to fear of vital sign abnormalities, says Stone. "Do not worry about low blood pressure in a terminal patient that is in pain; just titrate to symptoms," she says. Any patient who is suffering should be offered analgesia, advises Stone. "Studies show that most patients are undermedicated by ED staff," she says.1 "Too many patients die in pain," she says.
To provide effective pain management, you must educate yourself on drugs or dosage ranges that may be out of your comfort zone, says Key. "Terminally ill patients may be on huge doses of painkillers because of their condition, and ED nurses are not used to administering those dosages," she explains.
If you suspect a narcotics overdose in a patient with altered mental status, remember that reversing agents such as naloxone have a half-life of 60-90 minutes in adults, says McClain. "If you have used the standard doses we are used to giving in the ED, you will not be able to get the patient comfortable again for that time period," she explains.
Smaller than usual doses may give you the clinical information you need without causing undue pain to the patient, says McClain. "We need to not whip off fentanyl patches or aggressively push naloxone immediately upon arrival to the ED," she says. "We need to not give injections if oral medications are being effective."
• Explain the seriousness of the patient’s condition if necessary. Family members may not realize how serious the patient’s condition actually is, says Stone. Stone recently treated a cancer patient with necrotizing fasciitis, who was in her third relapse and was severely netropenic and septic. "I encouraged her daughter and son to speak with her before she might have to be intubated," she says. "I explained to them how ill she was and that her prognosis was grave." This explanation gave them the chance to have a final communication with their mother, who died in the intensive care unit the following day, says Stone.
• Find out what patients want. Patients have the right to decide what interventions they do and don’t want, stresses Stone. "Ideally, this is carried out with advance directives and respecting our patient’s wishes," she says. "This is hard for us in the ED because we are so used to treat it and fix it.’ But what many patients need is reassurance that their wishes will be respected."
There often are times when interventions do not have to be done emergently, says McClain. "Time can be taken to consult with the patient, family, and primary care physician to make sure we are all working together for the same goal of a good’ death as defined by the patient," she says.
1. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: Patterns of analgesic utilization. Pediatrics 1997; 99:711-714.
For more information about end-of-life care in the ED, contact:
• Susan Key, RN, Director of Emergency Services, Cape Canaveral Hospital, 701 W. Cocoa Beach Causeway, Cocoa Beach, FL 32931. Telephone: (321) 799-7156. E-mail: Susan.Key@health-first.org.
• Kay McClain, RN, MS, CEN, Nurse Director, Emergency Services, Marlborough Hospital, 157 Union St., Marlborough, MA 01752. Telephone: (508) 486-5520. Fax: (508) 229-1205. E-mail: McClainK@ummhc.org.
• Susan C. Stone, MD, MPH, FACEP, Assistant Professor, Emergency Medicine, University of Southern California and Los Angeles County Medical Center, 1200 N. State St., Los Angeles, CA 90033. Telephone: (323) 226-6667. Fax: (323) 226-6454. E-mail: firstname.lastname@example.org.
A position statement on care of terminally ill patients in the ED can be accessed free of charge on the Emergency Nurses Association (ENA) web site (www.ena.org). Under "Publications," click on "Position Statements," and scroll down to "End-of-Life Care in the Emergency Department." A book on improving end-of-life care in the ED is also available. The cost is $45 for nonmembers and $40 for members, plus a $10 shipping charge. To order from the ENA web site, click on "Marketplace," and under "Books/Journals," click on "Clinical Books," and "Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians." A pamphlet, End-of-Life Care, provides guidance in managing patient care situations. It is available at a cost of $15 for nonmembers with $4.50 shipping charge and $7 plus $3.50 shipping charge for members.