End of Life Care -EoLC in ED

GEMCON 2018 Chennai

1. End of Life care
decisions in ED
Dr.Venugopalan P P
DA,DNB,MNAMS,MEM-GW
Director -Emergency Medicine
Aster DM Healthcare

2. Dedicated to my teacher and mentor Padmasree
Prof.M.R.Rajagopal

3. “Dying can be a peaceful event or a great agony
when it is inappropriately sustained by life support”
Roger Bone
Bone RC. Reflections; a guide to end of life issues for you and your family.Evanston IL: National Kidney Cancer Association;
1997. You and I are dying; pp. 4–7

4. Case scenario
•86 year old lady presented to ED with shortness of breath,
chest pain and Generalised weakness and one episode of
seizure
•Known case carcinoma lung and CKD on chemo
•Not fully active since last 6 months
•Initial vitals -HR 126/mt, BP 86 systolic , RR 36/mt, Temp
102 F , GRBS 186mg/dl ,SpO2 87 in room air ,Pain Score
7/10
•Resident on duty initiated stabilisation process

5. Case scenario
•Her husband died few year back
•Two children - Son is software engineer and daughter is a
staff nurse both of them are settled abroad
•Caregiver communicated them and they want to do
aggressive
•Consulted Senior on duty - spoke with son and daughter
over phone . Decided to treat aggressively

6. Case scenario
•Intubated, NG, Bladder Cath, IJV and IBP done
•Blood chemistry done ,CT head and thorax , ABG done
•Oncology ,Nephro, Pulmonology and medical consult
done
•Admitted in ICU , On ventilator……

7. This session…
•What are the issues in ED ?
•Can it be managed differently?
•What are barriers ?
•What are the ethical issues in it ?
•What are the medico-legal issues in it?
•What is the Indian status in EoLC
EoLC

9. Evidences…
140,000 Australians who die each year
At least 100,000 of them die as a result of an
“anticipated” or “expected” death
Of the 140,000 who die each year, 54% die in
acute care hospitals; 20% die in hospices/
palliative care; 16% die at home; 10% die in
nursing homes
Elderly tend to be overrepresented in EDs
G. A. Caplan, A. Brown, W. D. Croker, and J. Doolan, “Risk of admission within 4 weeks of discharge of elderly patients from the emergency department—the DEED study,” Age and Ageing, vol. 27, no. 6,
pp. 697–702, 1998
E. K. Fromme, P. B. Bascom, M. D. Smith et al., “Survival, mortality, and location of death for patients seen by a hospital-based palliative care team,” Journal of Palliative
Medicine, vol. 9, no. 4, pp. 903–911, 2006




10. EoLC patients shifted to
Hospitals
In the past, the limits of conventional medical
treatment were largely determined by the general
practitioner (GP)
Now the GP to refer the patient to hospital when
the illness becomes severe and life is threatened
The GP often faces barriers when managing their
patients at EOL making their central role in home-
based care difficult.
Bone RC. Reflections; a guide to end of life issues for you and your family.Evanston IL: National Kidney Cancer Association; 1997. You and I are dying; pp.
4–7
Frost DW, Cook DJ, Heyland DK, Fowler RA. International Differences in End-of-Life Attitudes in the Intensive Care Unit: Results of a Survey. Crit Care
Med. 2011;39:1174–89. [PubMed]

11. Reality
India, depending on the case mix 10–
36% of patients admitted to ICU
and die.
Many when a therapeutic trial of
intensive care has failed, life-
supporting interventions only serve to
render the dying process more
prolonged and burdensome.
Parikh CR, Karnad DR. Quality, cost and outcome of intensive care in a public hospital in Bombay. Crit Care Med. 1999;27:1754–9. [PubMed]

12. Death
“A decent or good death is the one that is:
free from avoidable distress and suffering
for patients, families, and caregivers; in
general accord with patients’ and families’
wishes; and reasonably consistent with
clinical, cultural, and ethical standards”.
E. J. Emanuel and L. L. Emanuel, “The promise of a good death,” Lancet, vol. 351, no. 2, supplement, pp. 21–29, 1998

13. END OF LIFE CARE -EoLC
Patients at EOL comprise a wide range of
demographic, clinical, and psychosocial factors in
relation to time and place of death
Comprise a wide range of ages and conditions such
as cancer , terminal respiratory diseases , cardiac
failure , profound intellectual and physical
disability, and advanced dementia .

14. END OF LIFE CARE -EoLC
EoLC patients pose a challenge in the ED because
the majority appear not to have access to palliative
care options, in particular those with non-cancer
conditions
Patients are managed in the ED when palliative
management at home would have been more
appropriate if a transition from active to palliative
management had been made earlier
C. Shanley, S. Sutherland, R. Tumeth, K. Stott, and E. Whitmore, “Caring for the older person in the emergency department. The ASET Program and the Role of the ASET Clinical Nurse Consultant in South
Western Sydney, Australia,” Journal of Emergency Nursing, vol. 35, no. 2, pp. 129–133, 2009. 

W. Silvester and K. Detering, “Advance directives, periopera- tive care and end-of-life planning,” Best Practice and Research, vol. 25, no. 3, pp. 451–460, 2011.
W. Silvester and K. Detering, “Advance care planning and end-of-life care,” Medical Journal of Australia, vol. 195, no. 8, pp. 435–436, 2011. 


15. Terminology
End-of-life: is that part of life where a person is living
with, and impaired by, an eventually fatal condition, even
if the prognosis is ambiguous or unknown
End-of-life care:EOL care combines the broad set of
health and community services that care for the population
at the end of their life.
Palliative care: is specialist care provided for all people
living with, and dying from an eventually fatal condition
and for whom the primary goal is quality of life
Palliative Care Australia, Palliative and End of Life Care— Glossary of Terms, Palliative Care Australia, Canberra, Aus- tralia, 2008.
World Health Organisation, WHO Definition of Palliative Care, 2011, http://www.who.int/cancer/palliative/definition/ en/#.


17. EoLC

18. EoLC
Includes people whose death is imminent
(expected within a few hours or days)
1.Advanced, progressive, incurable conditions
2.General frailty and co-existing conditions
that mean that they are expected to die
within12months
3.Existing conditions, if they are at risk of
dying from a sudden acute crisis in their
condition
4.Life-threatening acute conditions caused by
sudden catastrophic events. 


19. EoLC
An approach that improves the
quality of life of patients (adults
and children) and their families
who are facing problems
associated with life-threatening
illness.
It prevents and relieves
suffering through the early
identification, correct assessment
and treatment of pain and other
problems

20. Care pathway in EOL

24. ABCD of Dignity
conserving Care
Attitude and
Assumption
Behavior
Compassion
Dialogue

25. Attitude and Assumption
Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007;335:184-187

26. Behavior
Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007;335:184-187

27. Compassion
Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007;335:184-187

28. Dialogue
Chochinov HM. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ 2007;335:184-187

29. EoLC in ED

30. EoLC in ED

31. Practical preparatory procedure to
ensure patient dignity before EoLC
Staff preparation

32. Practical preparatory procedure to
ensure patient dignity before EoLC
Staff preparation

33. Practical preparatory procedure to
ensure patient dignity before EoLC
Room preparation

34. Practical preparatory procedure to
ensure patient dignity before EoLC
Patient preparation

35. EoLC decisions
The common and uncommon material risks of
CPR/CCR and treatment may include:
•Incomplete recovery
•Prolonged death
•Uncomfortable investigations and treatments
•Ventilator dependence
Diem SJ, Lantos JD & Tulsky JA. 1996. Cardiopulmonary resuscitation on television: Miracles and misinformation. NJEM; 334: 1578-82.

36. Non-beneficial treatment
Interventions that will not be effective in treating
a patient’s medical condition or improving their
quality of life.
Include interventions such as diagnostic tests,
medications, artificial hydration and nutrition,
intensive care, and medical or surgical procedures.
Bone RC. Reflections; a guide to end of life issues for you and your family.Evanston IL: National Kidney Cancer Association; 1997.
You and I are dying; pp. 4–7.

39. Reversible causes of
dyspnea

40. Communication…

42. Considerations and Cautions in
the withdrawal of life support
Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of
life. Intensive Care Med 2008;34:1593-1599

43. Considerations and Cautions in
the withdrawal of life support
Variable Considerations Cautions
Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of
life. Intensive Care Med 2008;34:1593-1599

44. Considerations and Cautions in
the withdrawal of life support
Variable Considerations Cautions
Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of
life. Intensive Care Med 2008;34:1593-1599

45. Advance care directives

46. How to identify EoLC patients?
Tools-

47. ACEM
Australian College of EM
ACEM encourages use of screening tools, such as the Criteria
for Screening and Triaging to Appropriate aLternative
care (CriSTAL) and the Supportive and Palliative Care
Indicators Tool (SPICT), by EDs and emergency
physicians in order to identify elderly patients at the EoL
ACEM considers that these tools are essential in identifying
patients who are at risk of dying as well as when it is
time to begin discussions with these patients and their
families. 


48. CrisTAL
CrisTAL is a screening tool that identifies older patients at the EoL
and quantifies the risk of death in hospital or soon after discharge.
Minimise potentially harmful and non-beneficial treatment
Identify older patients who may benefit from care pathways that do not
involve hospitalisation
Encourage patient, family, carer and medical practitioner discussions
regarding the goals of EoLC
Identify EoL status before hospital admission include conditions such
as chronic heart failure or chronic kidney disease, as well as repeat
Intensive Care Unit (ICU) admissions at previous hospitalisations.
ref :Cardona-Morrell M, Hillman K. Development of a tool for defining and identifying the dying patient in hospital:
Criteria for screening and Triaging to Appropriate aLternative care (CriSTAL). British Medical Journal. 2015; 0: 1-13.

49. Checklist of 29 predictors of death, including:
• Age 65 years or older, plus either emergency admission for the current hospitalization
(associated with 25% mortality within 1 year) or two or more deterioration criteria, including
change on the Glasgow Coma Score, low systolic blood pressure, slow or rapid respiration,
low or high pulse rate, need for oxygen therapy or oxygen saturation less than 90%,
hypoglycemia, or repeat or prolonged seizures.

• Additional risk factors or predictors of short- to medium-term death, including personal history
of active disease (advanced malignancy, chronic kidney disease, chronic heart failure, chronic
obstructive pulmonary disease, new cerebrovascular disease, myocardial infarction,
moderate or severe liver disease, cognitive impairment), as well as previous hospitalization
within the last year, or repeat intensive care unit admission at the previous hospitalization.

• Other factors, such as evidence of frailty, residence in a nursing home or supported-living
facility, proteinuria, and abnormal electrocardiogram findings.


50. Supportive and Palliative care Indicators
Tool-SPICT
SPICT assists in identifying patients at risk of deteriorating
and dying in all care settings.
Tool also provides indicators which clinicians can use to identify
when it may be appropriate to initiate EoLC discussions with
patients and their families or carers.
Ref:The University of Edinburgh. Supportive and Palliative Care Indicators Tool (SPICT). The University of Edinburgh; 2016. 


51. SPICT
SPICT uses six indicators of deteriorating health.
1.Unplanned hospital admissions
2.Performance status is poor or deteriorating ,with limited reversibility
3.Dependent on others for care due to physical and/or mental health
problems
4.More support for the person’s carer is needed
5.Significant weight loss over the past 3-6 months, and/or a low body mass
index
6.Persistent symptoms despite optimal treatment of underlying condition(s)
7.Person or family ask for palliative care, treatment withdrawal/limitation
or a focus on quality of life 

Ref:The University of Edinburgh. Supportive and Palliative Care Indicators Tool (SPICT). The University of Edinburgh; 2016. 


52. ER role
Emergency physicians and ED staff should establish
a dialogue with patients at the EoL, as well as their
carers, families and health care workers or health
care team members, to ensure that there is a
common understanding of the goals of care.
Emergency physicians should advocate for the
documentation of a patient’s values and wishes
regarding medical treatment through advance care
planning processes.

53. Patients at EoLC
Routine ER care principles cannot always be applied
or implemented because these patients cannot be
treated in the same manner as patients with no terminal
conditions
Patients at EOL cannot be assessed and treated on
the same time-restricted manner as other patients
because they often present with multiple complications
and several complex conditions
Resuscitation and active treatment for these patients
may not be the best nor the preferred option

54. Patients at EoLC
The physician's approach to the patient has
three dimensions: medical, ethical and legal
Care of the critically ill involves not only the
application of complex and expensive life-
supporting interventions, but also, when
appropriate, their withholding or
withdrawal.

55. Patients at EoLC
The manner in which death is managed may affect
the survivors for the rest of their lives
Indian context, prolonged and futile life support has
undoubtedly imposed enormous economic and
human cost on patients and their families that is
avoidable
Scarce resources in terms of material and
manpower can be optimally utilized for salvageable
patients when released from futile applications

56. EoLC consensus 2003
American Thoracic Society, European Respiratory Society,
European Society of Intensive Care Medicine, Society of
Critical Care Medicine and Societé de Réanimation de
Langue Française.
Consensus conference symbolizes a transnational mission to
improving the care of dying patients in the ICU.
End-of-life care is emerging as a comprehensive area of
expertise in the ED and ICU and demands the same high
level of knowledge and competence as all other areas of ED
and ICU practice
Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU: Statement of the 5th International Consensus
Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Medicine. 2004;30:770–84. [PubMed]

57. EoLC decisions : Barriers in
India
Unawareness of ethical issues
Culture of heroic “fighting till the end,”
Lack of palliative care orientation
Legal and administrative prejudices
Absence of guidelines for withdrawal
and withholding of life support in
Indian laws
Balakrishnan S, Mani RK. The constitutional and legal provisions in Indian law for limiting life support. Indian J Crit Care Med. 2005;9:108–14.

58. EoLC in India
Recently, the Economist Intelligence Unit (EIU) ranked India's
end-of-life care last out of 40 countries
India was reported to have scored poorly in all of the indices:
basic end-of-life care environment, availability, cost and quality
of EOLC.
The EIU gave India a score of 2/5 in public awareness of
EOLC, which the report attributes in part to Indians’ reluctance
to openly discuss death and dying.
EIU also reported “lamentably poor” palliative care system in
all parts of India except in Kerala, where there exists a
community-driven hospice service.
Economist Intelligence Unit. Commissioned by LIEN Foundation. The quality of death: ranking end of life care across the world.
[Last accessed on 2010]. Available from www.eiu.com/sponsor/lienfoundation/qualityofdeath]

59. EoLC in India
LAMA in India often refers to a unilateral withdrawal
decision by the family mainly because of unbearable
financial and other burdens especially since the private
sector dominates health-care delivery
Physicians may tacitly endorse this practice as the only
way to prevent perceived social and legal
complications
Jayaram R, Ramakrishnan N. Cost of critical care in India. Indian J Crit Care Med. 2008;12:55–61. [PMC free article] [PubMed]
Mani RK. Limitation of life support in the ICU. Indian J Crit Care Med. 2003;7:112–7

60. EoLC in India
Half the EOLDs took place in the first week after admission to
ICU.
Advanced chronic disease, premorbid fully dependent state
and unresponsiveness to treatment were most frequently cited
reasons for these decisions.
EOLD was not independently associated with age, APACHE 4
at 24 h of admission and co-morbidities.
EOLD significantly reduced the therapeutic and cost
burdens towards the last 3 days of life.
Jayaram R, Ramakrishnan N. Cost of critical care in India. Indian J Crit Care Med. 2008;12:55–61. [PMC free article] [PubMed]

61. EoLC in India
The physician's orientation by his training is only
to a curative rather than palliative approach to
disease no matter the phase of the illness.
Physician is generally fearful of being accused of
providing sub-optimal care or of possible
criminal liability of limiting therapies.
A virtual absence of legal guidelines (although
professional ethical position has been available
since 2005) relating to deaths in intensive care
units/ED in India

62. DNR
DNR means no resuscitation in the
setting of a full cardiopulmonary arrest.
This is often misinterpreted, and
sometimes associated with lower
quality or less care.
Patients can and should still receive full
and aggressive medical management
even if they are rendered DNR
DNR and Euthanasia are not legally
valid in India

63. AND vs DNR
AHA Cardiopulmonary Resuscitation Guidelines in
2010, towards changing the DNR order to ‘Allow
Natural Death’ (AND)
AND uses positive language, stating what we  will do, as
opposed to what we  will not do.
Patients and their families may feel less guilt and may be
more likely to be agreeable to an AND order than to a
DNR order.

64. Prognostic signs in EoLC
Delirium with hypotension
and tachycardia: median
survival 10 days
Death rattle: medial
survival 1 day
Respirations with
mandibular movement:
median survival 2.5 hours
Cyanosis to extremities:
medial survival 1 hour

65. Sudden or expected
death in ED
The care of the bereaved relative is as important as the care given to the
dying patient

66. Breaking Bad news
Breaking bad news should be carried out by
the most experienced clinician available
who knows the patient.
The doctor should be sensitive of religious,
cultural or other needs of the family.
A good starting point is to find out what the
family already know about the patient’s
current condition.

67. Breaking Bad news
Bad news should be communicated in a
timely and sensitive way, avoiding
euphemisms and jargon.
Listening is as important as talking when
breaking bad news.
A nurse should accompany the doctor
when breaking bad news in order to
support the family.

68. After death
care
Care of bereaved
relatives
Procedures to
declare death
Staff support

69. Summary
Emergency room has a pivotal role in EoLC
Palliative care starting in the ED is to help patients and their
families focus on their goals of care
The EP must evaluate the disease trajectory and overall
function of the patient to help guide further treatment options
When developing the next steps, the EP must be honest yet
gentle in discussing prognosis
The shift from curative to non curative treatment improves
patient satisfaction and decreases use of valuable resources
EP can coordinate with Palliative team, Primary consultant, GP
family effectively

70. LIFE WITH DIGNITY ….
DEATH WITH DIGNITY ..???