ED Case Corner

The newsletter editors are pleased to introduce this new addition to the palliative section newsletter. We will use actual cases to highlight how palliative care made a difference for an emergency department patient. Contributions welcome! (500 words or less).

CASE CORNER

Palliative Care of a Dying Patient in the ED: An RN/MD Collaboration
Victoria Robertson, R.N. and Rachel Pearl, M.D.

Christmas morning, 4 A.M. Our ED receives a radio call for an incoming patient. She is a 71-year-old woman with metastatic liver cancer out on a "pass" from her hospice facility staying with her sister for the holiday. She is vomiting blood. On arrival to the ED she is minimally responsive. She is cachectic, icteric, bradycardic, and hypotensive. Her respirations are labored. She is alone and clearly too ill to partake in her own care.

The patient’s sister has forwarded a binder with EMS. There is abundant paperwork, but nothing regarding code status. She has never been a patient in our network. We try to get information from the hospice service, but computers are down. I phone the patient’s sister, who is distraught. She explains why she called 911: there was blood all over her kitchen floor and she didn’t know what else to do. Family is coming into town today and she needs to clean up the mess. As far as code status, she cannot say.

Meanwhile, decisions must be made about this patient’s care. Do we intubate? Central line? Pressors? We all agree we must confirm her wishes. After much effort, one of our nurses calls back and carefully redirects the panicked sister. She is finally able to identify the patient’s hospice residence. A faxed POLST confirms our suspicion: DNR, with comfort measures only. With this information, I ask the ED physician if we can provide something to make this patient more comfortable. The apprehensive response is, “There’s a fine line between making someone comfortable and killing someone.”

I invite the physician to the patient’s bedside so that we can assess her together. We have a brief discussion and develop a plan of care. We are in agreement that an order for morphine is completely within reason. We administer a small bolus, after which the patient appears more comfortable. Her breathing is less labored and she ceases to grimace. A morphine drip and glycopyrrolate are ordered. We are going to make the process of dying as dignified and serene as possible.

Hours after our patient dies, her sister arrives to the ED. I realize the original ED physician has since gone home. Our new physician was not involved in the case, but offers to meet with her. I privately wonder: who should break the bad news? A physician, with formidable expertise and a distinctive white coat, but who never interacted with this patient? Or me, the nurse who was at the bedside when this patient took her last breaths? I assume the role that feels most natural. As the patient’s sister weeps, I listen to stories, look at photos and hold the hand of our patient’s loved one for nearly 2 hours.

Inarguably there is a clear differentiation between physician and RN roles. However, the ability to collaborate, to assess a patient and environment together, and to trust each other is invaluable to the quality of end of life care provided in the Emergency Department.