Morning Report: 6/4/2013

Today’s Morning Report is thanks to Dr. Chapman!

This Morning Report is based on the Emergency Medicine Practice Article, Emergency Management of Dyspnea in Dying Patients; the following Vignette is also based heavily on the vignette in the article:

It’s 2 a.m. You’re in the middle of a busy CCT shift when EMS calls with the following notification: 55y.o. F in severe respiratory distress, 2 minutes out. You double check the airway carts and page respiratory. When she arrives, you note that she is cachectic and pale, pulling off her non-rebreather and gasping for air. Her daughter walks alongside the stretcher, crying. The patient appears to be terminally ill, and when you ask her daughter what’s going on, she says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” Faced with this uncomfortable, dying patient, the traditional emergency medicine tools of intubation and ventilation are clearly inappropriate, but what other medical strategies exist to help this distressed, terminally ill patient? Her daughter pleads, “Please help her, doctor. I can’t watch her suffer like this.” How can you be sure she gets the right treatment in spite of your limited resources?

Ask yourself, How soon will this patient die? It determines how aggressive your treatment will be.

Dyspnea is one of the most common symptoms encountered by patients with terminal cancer. 70-80% of patients experience it at some point during their last 6 weeks of life.

Across all cancer patients with uncontrolled, progressive CA + dyspnea, studies show prognosis is usually <2 weeks.

Solid tumor patients spending >50% of their time in bed = average prognosis of < 8 weeks

End-stage CHF, COPD, Liver Failure= harder to predict. Aggressive treatment of acute compensation = pts often recover, even though they may have presented with extremely abnormal vital signs

Physical findings suggestive of imminent death (in absence of unrelated, reversible process, i.e. pneumothorax, acute fluid overload):

Hours to days–death rattle (23h), respirations with mandibular movements (2.5h), cyanosis to extremities (1h)

Days to weeks (usually 2 or less)—vital sign derangements—tachypnea, tachycardia, hypotension, delirium/drowsiness (esp if acute change)

Assess desired level of Care:

NEVER ask, “do you want everything done?” “do you want to be intubated?” Be sure to be specific. For example, surveys have shown that most patients and their family members believe intubated patients are fully able to communicate.

SILVER:

Seek information—baseline level of functioning; diagnosis, prognosis, and treatment plan; who are the key players in medical decision making? Is there a Physician Order for Life-Sustaining Treatment (POLST or MOLST) or living will available? These documents are generally more detailed and specific than a DNR order.
Life Values-how does the patient view death and dying? What is the pt’s personality and overall approach to life (quality vs quantity?)
Educate/Extend Care-provide information on the pt’s disease process, condition, treatment options and how decisions now will affect future EOL care; if you have time, writing down several main points (3-4) of your discussion with the family in the d/c instructions can be helpful
Respond–solicit questions, offer support

After ruling out another cause of dyspnea, such as PE, MI, what are some things we could do to make this patient more comfortable?

-Oxygen or compressed air (studies don’t actually show much difference between the two)

-Bronchodilators, especially if wheezing

-If the patient is on hospice, attempt to contact them–#1: they will know almost everything about the patient’s medical history, #2: they have 24hour services and may send a nurse to assist with care

-you may do all or parts of the standard workup, based on how invasive the pt wants you to be with diagnosis and treatment

-Remember that treatment also varies depending on the patient’s wishes (another reason to contact hospice and get advanced directives)

-Opioids-evidence suggests oral and parenteral are most effective; no evidence to suggest certain opioids are consistently more effective than others at relieving dyspnea; ‘start low and go slow’ especially if patients are opioid nieve, and remember to adjust for renal failure-start lower, give less frequently

-one study: dyspnea relief with 2.5mg oral hydromorphone (0.4mg IV)

-recommended initial dosing: OPIOID NIEVE: 1-2mg of morphine IV or 0.2-0.4mg IV dilaudid, reassess and double every 10minutes if needed, until dyspnea is controlled OPIOID TOLERANT: start at 10% of the total daily dose, then adjust as described above

-nebulized saline-may help dyspnea by breaking up secretions

-can add benzos in low doses—i.e. 1-2mg of Ativan po, if you suspect there is a strong component of anxiety

-consider scopolamine (comes in patches= onset delayed by 6-8hours), atropine (can give 1-2drops of ophthalmic solution po q2-4h), glycopyrrolate (0.2mg IV/IM q6h) if repositioning fails and your pt has difficulty clearing secretions (i.e. death rattle; evidence is not great)

Nonpharmacologic therapies:

-handheld fans (?)

-call spiritual leader—rabbi, chaplain, etc when appropriate, consider social work (i.e. anxious patients)

-call family members/significant others and palliative care consults EARLY/ASAP

-NIPPV may help, BE JUDICIOUS-if a patient is a palliative case and clearly uncomfortable wearing it (and you’re sure hypoxia isn’t a confounding factor), remove it.

-Remember: goal is SUBJECTIVE relief of dyspnea; you ARE NOT trying to normalize respiratory rate or oxygen saturation in a true palliative case

After an assessment of the patient and review of her chart, you become concerned that this patient may be in the last days to weeks of her life. A brief discussion with the patient reveals that she is confused and too distressed to participate in decision-making, so you take the daughter to a quiet corner of the ED to talk. When you ask, “What have the doctors told you about your mother’s condition?” the daughter responds by saying, “She’s dying. I know. But I can’t manage this at home.” You validate her concerns and decision to call EMS and ask, “Knowing that her time is short, what would be most important to her right now?” Her daughter explains that she “doesn’t want to suffocate.” You assure her that you will do your very best to support these goals. You find a quiet, private room in the ED and have the patient transported there. A chair is placed next to the bed so that the daughter can be with her. You use the IV placed by EMS to deliver medication. Her daughter reports that “she takes a Percocet® every now and then, but that’s it,” so you consider her relatively opioid-naïve. You order morphine 1 mg IV. After this, her respiratory rate declines from 40 to 35 breaths per minute, but it still appears labored. You administer morphine 2 mg, and then 4 mg, in 10-minute time intervals. After this last dose, the patient’s respiratory rate decreases to 20 and her face appears relaxed, with her accessory muscles no longer visible with breathing. A plan is made to transfer the patient to the palliative care unit in the morning, when a bed becomes available. When you update the patient’s daughter regarding the plan, she says, “Thank you. I really appreciate everything you’ve done. She looks so peaceful.”

REFERENCES:

Fernandez R, et al. “Development of a Content Valid Tool for Assessing End-of-Life Communication in Acute Care Settings.” Journal of Palliative Medicine. 2012;15(4):381-387. Used with permission of Mary Ann Liebert, Inc.

Shreeves, A. et al. EMP: Emergency Management of Dyspnea in Dying Patients. May 2013. https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=364