70 F Found down

Colleague Collateral

• On 4th line treatment for myeloma
• Last in ED one week ago for constipation
• Discharged home same day with spouse, stable

Patient arrives

• Looks awful
• 100/72 105 22 35.8 95% RA GLU 4
• Full code, husband en route
• What is your approach?

Myeloma Patient moaning in pain

What do you reach for? No IV access...

Myeloma patient appears dyspneic

• Likely has bilateral infiltrates
• Unclear if she would benefit from escalation of therapies
• Nurses distressed at how SOB she appears
• RR now 60, grimacing, pain more under control

Your patient is now oozing blood from all IV sites, mouth. PLT 10

Myeloma patient expresses + nausea then vomits++. What would you reach for (N QTc on EKG)

Back Pain/Weakness

• Myeloma
• Known spinal disease
• Now weak (since yesterday, collateral from husband), cannot ambulate
• Query incontinence since this am

labs

Yikes

• K 8.0
• Calcium 1.9
• Creatinine 722
• Uric acid 612

Post resuscitation

summary

• intubated, ventilated
• CVC, art line, 2 pressors
• Hyper K treatments
• Persistant hypoglycemia
• BS abx
• ICU consulted...grim prognosis with TLS and likely septic shock
• ICU team busy, husband wishing for update

Meet w spouse to communicate news

Communication in ED

Objectives

• Have an idea of ACP/GOC in ED
• Communication approach
• MOST forms
• Simulated case

Not intended to be comprehensive

ACP

• A process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, preferences regarding future medical care.
• Identification of SDM
• Done in advance of situation when they are incapable of making decisions
• May document Representative Document, helping to guide SDM

Communication Do's

• be direct and honest
• present prognostic information as a range
• allow silence
• acknowledge emotion
• make a recommendation *
• document conversation

Communication Don'ts

• Talk more than half the time
• Give premature reassurance/false sense of hope
• Provide factual information in response to strong emotions
• Inappropriate medical language

Phrases to avoid

• Do you want CPR?
• Do you want us to do everything possible?
• Will you agree to discontinue care?
• It's time to talk about pulling back
• I'm going to make sure that he/she won't suffer

Language to try on...

• I want to give the best care possible
• We will concentrate on improving the quality of your life
• I want to ensure that your parent receives the kind of treatment they want
• Your parent's comfort and dignity will my top priority

MOST FORMS

acute dying recognition/orders

Physical signs

• Breathing/RMM
• Secretions/rattle
• Radial pulse lack
• Peripheral cyanosis

EOL Orders

• Opiate e.g. Hydromorphone 1-2 mg iv/sc q 20 min
• Midazolam 1-5 mg IV/SC q 20 min
• Glycopyrrolate 0.4 mg SC q 3 h PRN
• Haldol 0.5-1 mg SC q 2 h PRN
• Methotrimeprazine 2.5-5 mg SC q 2h PRN

Palliative POCUS

thoracotomy

halo