Palliative Aspects of Emergency Care

Chapter 1: Overview

Chapter 2: Trajectories and Prognostication in Emergency Care · Emergency Department and Functional Trajectories · Prognostication and Prognostic Tools o Cancer o Heart Failure o Chronic Obstructive Pulmonary Disease o Dementia · Communicating the Prognosis · Creating a Plan of Action

Chapter 3: Rapid Palliative Care Assessment · The Critically Ill or Unstable Patient · The Medically Stable Patient

Chapter 4: Cancer Emergencies · Spinal Cord Compression o Pathophysiology o Epidemiology o Signs and Symptoms o Diagnosis o Interventions § Corticosteroids § Radiation Therapy § Surgery § Bisphosphonates · Superior Vena Cava Syndrome o Pathophysiology o Etiology o Signs and Symptoms o Diagnosis o Interventions § Radiation Therapy and Chemotherapy § Endovascular Stenting o Prognosis · Hypercalcemia of Malignancy o Pathophysiology o Interventions

Chapter 5: Malignant Pain · The Cancer Pain Emergency · The Emergent Pain Assessment o Pain scales o Classification o Opioid naïve and opioid tolerant · Pharmacologic Management o Choosing an Algorithm o Using Equianalgesic dosing tables o Calculating the Initial Dose of an Opioid o Advanced Age, Renal Impairment, and Hepatic Impairment o Routes of Administration and Pharmacokinetics o Pain Reassessment after Treatment o Opioid Side Effects and Toxicities § Sedation and Respiratory Depression § Nausea and Vomiting § Myoclonus § Constipation · Confrontation of Barriers · Methadone · Non-Opioid Pharmacologic Management o Neuropathic Pain o Bone Pain o Other Approaches

Chapter 6: Non-malignant Pain · Pain Pathophysiology · Physiologic and Clinical Differences between Acute and Chronic Pain · Definitions o Tolerance o Physical dependence o Addiction o Pseudoaddiction · General Principles for Managing Chronic Pain · Policies Informing Emergency Department Management of Chronic Pain · An Emergency Department Approach to Managing Chronic Pain

Chapter 7: Symptom Management · Dyspnea o Pharmacologic approaches § Oxygen § Opioids § Anxiolytics o Complementary and Non-Pharmacologic Approaches · Delirium · Anxiety · Fatigue and Weakness · Insomnia · Fluid Balance and Edema · Nausea and Vomiting · Constipation · Diarrhea

Chapter 8: Spiritual Suffering and Bereavement · Definitions · Grief: Normal and Complicated · Spiritual Needs in the Emergency Department o Role of the Clinician o Role of the Chaplain · Rapid Spiritual Assessment · Responding to Hoping for a Miracle.

Chapter 9: Communication · Breaking Bad News · Death Disclosure · Special Considerations o Culture o Requests to Withhold Information o Telephone Notification o No Next of Kin Available o Communicating with Children · Death of a Child o Sudden Infant Death Syndrome o Miscarriage or Stillbirth · Self-Care and the Care of Other Emergency Department Staff

Chapter 10: Resuscitation, Family Presence, and Last Hours of Living · Cardiopulmonary Resuscitation and Prognosis in Advanced Illness · Family Presence During Resuscitation · Witholding or Withdrawing Interventions o CPR o Intubation and Artificial Ventilation o Artificial Nutrition and Hydration o Antibiotics · Care of the Actively Dying Patient o Environment o Symptom Control o Secretions o Dry Mouth o Agitation o Opioid Toxicity

Chapter 11: Hospice · Understanding Hospice Care o Eligibility o Underutilization o Scope of Services and Reimbursement o Discontinuing Hospice Care · Emergency Department Management of Patients under Hospice Care · Common Presentations · Initiating New Hospice Referrals from the Emergency Department

Chapter 12: Legal and Ethical Issues of Palliative Care in the Emergency Department · The Interrelation of Law, Ethics, and End-of-Life Care · Informed Consent · Limitation of Treatment · Determination of Decision-Making Capacity · Decision-Making for the Incapacitated · DNR Orders and Physician Orders for Life-Sustaining Treatments · Opioids and End-of-Life Care · Suicide and Physician-Assisted Suicide · Futility