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Palliative Medicine

Palliative Care Toolkit for EM Providers

The ACEP Palliative Care Toolkit for the emergency department mentioned in the last newsletter is up and running. Congratulations to all the hard work put in by our section members. See below the updated palliative care toolkit started in 2013 and presented at the ACEP14 meeting. You can also find it posted on our ACEP Palliative Medicine Section website. Our next steps are to consider applying for grants to help improve, educate and implement our toolkit. PDF version is also available for download. 

 

ACEP PALLIATIVE CARE TOOLKIT 

 

Triage Screening (by any team member: MD, RN, CM, SW, NP, PA):

Screen for Palliative Care (PC)-Eligible Patients


- Serious non-survivable illness AND with any of the following:

ToolkitChart

Provide General Palliative Care Patient Information

- Consider providing pre-interview a neutrally worded informational handout to introduce palliative care concepts and value proposition: 

 

Point-of-care Interventions:

Treating Common Distressful Symptoms  


SYMPTOM DRUG TO CONSIDER DOSE TIPS
Pain Opioids 
[dose conversion]
10-20% of current total daily
dose for breakthrough
 After 1st dose
- for moderate pain, increase 50%
- for severe pain, increase 100%.
Nausea/
Vomiting
Haldol 0.5-2mg IV or PO Prolongs QT –> check EKG
Dyspnea Morphine 2-4mg IV or 10mg po Unlikely to depress respiratory drive
at this dose


Ativan 0.5-1mg IV or po Second line may worsen delirium
Delirium Haldol 0.5-2mg IV or po Search for underlying cause
Terminal secretions Glycopyrrolate  0.1mg IV or 0.2mg PO Reduces respiratory gurgling
  Atropine 1%
ophthalmic gtt
 1-2 drops sublingual  
 

Goals of Care (GOC) Discussion
Format: “You and I Feel Good Talking; it’s our Ultimate Responsibility

                                     What is your Understanding of your illness?
                May I update you with more Information on your illness?
 Address verbal and nonverbal cues forFears.
                                    What are your Goals as you think about where we go from here?
                                                 What Tradeoffs do you see in considering your options?
                               What would be an Unacceptable outcome for you?
Based on our discussion, here is what I Recommend for next steps.

* If surrogate, frame in terms of “what the patient, not surrogate, would have wanted”
* Consider wording such as: aggressive comfort care vs. aggressive curative approach

 

After your assessment and interventions:

Disposition (leverage ED case manager or social worker)

 DispositionChart

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