Palliative Care Initiatives
In our efforts to improve the care of our patient population with serious and life-limiting illnesses, there are several ongoing palliative care initiatives within the ED. Please reach out to me if you have any questions or concerns about the following. My cell phone is 646-266-9281 and do not mind being called (during daytime hours) if issues arise concerning these patients. Email works great, too!
1. Intubation and central line procedure notes
There is now a “Goals of Care” component to these procedure notes. Please be honest when completing these. Sometimes there won’t be time to ask about advance directives (happened to me this week). That’s ok. Just check the answer that best applies.
“In patients with advanced disease, the potential harm of intubation and resuscitation may outweigh the benefit”
Prior wishes regarding intubation known?
Yes
Patient/surrogate unsure
Unable to ask
Did not ask
Prior wishes regarding attempt at resuscitation known?
Yes
Patient/surrogate unsure
Unable to ask
Did not ask
2. Admit order
There is now a question asking “Does patient qualify for palliative care?” with the following options available
End-stage HIV Dementia Bed-bound End-stage liver Stage IV cancer No
This is part of a palliative care “needs assessment” for the ED and hospital and will NOT actually affect your patient’s care, meaning the palliative care team will NOT be notified.
3. Direct ED to PCU admits
There are many patients who would benefit from going straight from the ED to the PCU. The palliative care department is in agreement that patients meeting the following criteria should be strongly considered for a direct admission to the PCU (sometimes under the care of VNS Hospice). In all cases, notify the palliative care team (917-632-6906). If you receive any resistance for cases meeting these criteria, PLEASE let me know.
Criteria for Direct ED to PCU admission
1. Patient with decision-making capacity and if not, surrogate decision maker easily identified
2. Patient groups
a. Actively dying patient (prognosis of hours to days)
-Goals: maximize comfort, not prolong dying process, DNR/DNI
-Unstable for transport outside the hospital to place like home with hospice, Haven, Calvary or NH with hospice
b. Advanced dementia ( BEDBOUND, TOTAL CARE, AT LEAST FAST stage 7C)
-hospitalization for FTT, dehydration, infection, fall PLUS an ACTIVE SYMPTOM
-Goals:
– maximize comfort ONLY; DNR/DNI
OR
– prioritize comfort but also desire time-limited trial of IVF or antibiotics, do NOT want to escalate care further if treatments unsuccessful, want to minimize burdensome interventions like lab draws, continued blood pressure monitoring, blood glucose fingersticks, etc…; DNR/DNI
Functional Assessment Staging (FAST)
Stages
1. No difficulties
2. Subjective forgetfulness
3. Decreased job functioning and organizational capacity
4. Difficulty with complex tasks, instrumental ADLs
5. Requires supervision with ADLs
6. Impaired ADLs, with incontinence
7. A. Ability to speak limited to six words
B. Ability to speak limited to single word
C. Loss of ambulation
D. Inability to sit
E. Inability to smile
F. Inability to hold head up
Thanks in advance your help with these tough cases!!!
Ashley
