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Chapter 189: Palliative Care

Kate Aberger

INTRODUCTION

The goal of palliative care is to relieve suffering of patients and families who live with serious illness. It is imperative to ascertain goals of care while concurrently stabilizing or temporizing the patient clinically and treating symptoms. We need to then compassionately communicate diagnosis, prognosis, and treatment alternatives and guide the formulation of a therapeutic plan.

IDENTIFYING PATIENTS FOR PALLIATIVE CARE

It is important to recognize when patients have unmet palliative needs and have a rapid palliative approach to these patients. See Table 189-1. Patient and family expectations can be managed by expert formulation and communication of prognosis. Prognosis will also guide treatment options. The most important factor in formulating a prognosis is functional ability. Generally, components of functional status which herald a poor prognosis and may indicate that the patient is on the dying trajectory are loss of the ability to care for oneself, unintentional weight loss, inability to ambulate, inability to maintain oral intake, and declining level of consciousness.

Table 189-1

Common Diagnoses and Key Findings of Patients Who May Benefit from Palliative Care

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Table 189-1

Common Diagnoses and Key Findings of Patients Who May Benefit from Palliative Care
Diagnosis Key Findings
Solid organ neoplasm Widespread metastasis unresponsive to treatment
End-stage heart failure Significant symptoms at rest despite therapy
End-stage COPD Significant symptoms at rest despite therapy
Advanced dementia Impaired mobility and inability to communicate health needs
Degenerative neurologic disease Inability to complete ADLs or communicate health needs
End-stage AIDS Multiple opportunistic infections and/or AIDS dementia
End-stage renal disease Patient no longer willing or able to undergo dialysis
End-stage liver disease Repeated episodes of hepatic encephalopathy, bleeding, or symptomatic ascites resistant to medical therapy
End-stage rheumatologic disease Inability to complete ADLs without significant discomfort
Multisystem trauma Nonsurvivable injury
Burn When age plus percent burn exceeds or nears 140
Multiorgan failure When two or more key body systems fail
Any chronic, progressive, debilitating disease Whenever symptom burden exceeds resources and the ability of the patient and/or family to cope with medical condition; Caregiver and/or family distress or conflict

Abbreviations: ADLs, activities of daily living; AIDS, acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary disease.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

  1. While decision-making capacity and goals of care are being sorted out, symptoms must be aggressively managed.

  2. Identify who is making decisions for the patient. If the patient can make their own decisions, they should guide their own care. If their symptom burden is too high for them to participate, or they otherwise lack decisional capacity, the patient's advance directive should be accessed and the named surrogate decision maker should be contacted as soon as possible. If no written advanced directives or POLST/MOLST forms exist, have they expressed their wishes to a proxy? Even if there is no legal proxy, the closest family members ...

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