Palliative Refresher for the ED

Outline

• Case discussions
• Case-shock
• Communication/EMR
• Prehospital Palliative Care
• Quick symptom hacks
• Balint
• Brief Emergency Reviews: TLS/Checkpoint Inhibitors
• Q & A

54 M CTAS 1

• hypoxic (70s)
• hypotensive (80's)
• tachypneic
• GCS 9
• tachy
• afebrile

Info

• oral chemo for myeloma
• last rx on pharmanet from community palliative care NP
• last code status FULL
• last ONC note-'disease response'
• dude is dying...

next steps?

Symptom cases?

Communication cases?

Useful language for assessment of values

"What would be important to you if time were short?"

"What are you willing to go through for more time?"

Baseline function of patient??

procedure q

• CPR?
• intubation
• pressors
• "everything"

values q

• understanding of illness
• baseline
• what are you willing to go through
• minimum quality of life

Do advanced even directives work?
*Not proven to causally change EOL care*

How do you broach Palliative Care in the ED?

Palliative Care vs. Hospice Care

What if you have no SW?

Consider Chaplain or Indiginous Health

Symptom hacks

What are you using for nausea these days?

Olanzapine

• Has a role for CINV
• Multiple receptors in the CINV pathway (5HT 2,3,6 & Dopamine D1,2,3,4)
• 5-10 mg PO daily
• Supportive Care in Cancer 2021

Akynzeo/NEPA

• Netupitant + Palonosetron
• Oral and IV
• NK1 antagonist with 5HT 3 antagonist
• CINV

Pain?

Magnesium

• NMDA antagonist
• prevents central sensitization and may attenuate preexisting pain hypersensitivity
• prevents calcium from entering cell (intracellular calcium plays a role in central sentisization)

Mg suggested uses

• neuropathic pain
• migraine
• post herpetic neuralgia
• dysmenorrhea
• fibromyalgia
• Perioperative

Immune Checkpoint Inhibitors

How do they work?

• Monclonal antibodies
• Prevent immunosuppression by blocking engagement of checkpoint molecules
• 'Reinvigorating' an antitumour response

Examples

• Expanding uses
• NSCLCA, RCC, melanoma
• e.g. combo ipilimumab&nivolumab led to 5 year survival in met melanoma of 52%

Toxicities

• up to 72% of those treated
• mild to severe
• most important to think of it
• talk with Med Onc on call and discuss role for steroids

Future (present?)

take away

• EMR can be your friend
• language is important
• palliative care is not synonymous with EOL care
• try Magnesium & Olanzapine in ED

take away

• ketamine has lots of uses
• beware of ICI toxicities
• TLS may be more common
• psilocybin is here

?