Palliative Care

Basics

Description

  • Patients with serious and advanced illness commonly seek care in the emergency department
  • About 20% of ED patients will have a life-limiting diagnosis. >75% of patients will have an ED visit within the last 6 mo of life and 50% will have an ED visit within the last month of life. Many will have unmet palliative care needs
  • Early palliative care intervention is associated with improved patient satisfaction, decreased length of stay and cost, and in some populations longer survival
  • Palliative care focuses on quality of life and reducing symptom burden for patients with serious illness and can be provided at any point in the course of illness alongside disease-directed and life-prolonging treatment
  • In the US, hospice is a specific insurance benefit offered when expected prognosis is 6 mo or less, and in which life-prolonging treatment is generally discontinued in favor of symptom management and psychosocial support

Code Status And Advance Care Planning

  • Patients with capacity or valid surrogate decision makers may determine and change goals of care and preferences for life-sustaining treatment at any time:
    • Surrogate decision makers include: Health care proxy (HCP), durable power of attorney for health care (DPOA), health care agent (HCA), and next of kin (in states with next of kin hierarchies)
    • Clinicians should be familiar with surrogate decision-making regulations in their state and facility
  • Surrogate decision makers are only valid when the patient lacks capacity:
    • However, a patient with capacity may also choose to defer decision making to a surrogate
  • For any discussion around a treatment decision or code status, best practice is to explore illness understanding and baseline function (level of function, symptom burden), explain the medical decision that has to be made (full code vs DNR, emergency surgery, etc.) and the impact of these decisions, and then explore goals and values (including quality of life they would find unacceptable)
  • Rather than offering a “menu” of options, the clinician should make a treatment recommendation that best aligns with the patient’s goals and values
  • Advance care planning documents are legal documents that enable a patient to specify treatment preferences in advance, including decisions about code status, health care agent selection, and end-of-life wishes:
    • These documents should be used for guidance but do not supersede the current wishes of the patient or valid surrogate.

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