I am incredibly excited to welcome Patrick Bafuma on board as a guest author to Injectable Orange. Patrick is an Emergency Medicine Physician Assistant in Hudson Valley, New York. This role was quite foreign to me before “meeting” Patrick. The physician assistant practices medicine under the supervision of a Physician or Surgeon with a similar scope to an early training resident Doctor, but with a vastly greater contextual experience in their field of employment. This brings a unique and interesting experience and perspective to Injectable Orange. Patrick writes punchy, succinct articles grounded in mini-literature reviews on topic and contextualised to his experience (see more at EMinFocus.com).
Enjoy – Jesse (@inject_orange)
If you have worked in the Emergency Department long enough, you readily recognise the patients that are imminently going to die. The young man with a herniating bleed, normotensive and beginning to become bradycardic. Stage IV colorectal cancer, with free air under her diaphragm.
I’ve often half-jokingly stated that we treat our pets better than our family at the end of life. Our beloved Fido dies after a run on the beach, a steak dinner, and with a slug of morphine…. Grandma? She gets intubated without pain medication, gags a bit, and likely dies in significant distress.
We CAN make this process more peaceful. There is a significant movement for emergency medicine to OWN palliative care. We need to recognize when heroic efforts will go for naught (1 year mortality for a patient >85 years old admitted to the ICU is 97%). We can be soothing. We can start Fentanyl drips. We can add anti-secretory agents. We can deliver on anxiolysis.
As per a recent study, according to the family of the deceased:
‘What factors were associated with the perception of peaceful death?’
Adequate personal attention.
Adequate personal care.
Family finds enough nurses available.
And ability to make a phone call.
Religious affiliation consideration in end-of-life decision making has been associated with the perception of a peaceful passing. Simply offering a chaplain to come in for support, often times is soothing to the family and facilitates a sense of closure. There is something about the end of a loved one’s life that brings out an inner spirituality from both atheists and believers. This is so simple to do! If the RN asked me if they could page the chaplain for my dying patient, I would be embarrassed I had yet to do it myself. It is one of few things that we may all do that has been shown to influence a family member’s perception that their loved one passed peacefully.
Next time it appears futile, think benefits versus burdens. As the end-of-life discussion occurs, offer a chaplain. The conversation and the weight of reality is never going to be easy for the family. Let’s make an honest attempt to make it less difficult. Let’s turn off the monitor, turn on the Fentanyl drip, load the patient with Hyoscine, and bring the chaplain into your team.
When do people with dementia die peacefully? An analysis of data collected prospectively in long-term care settings
PMID:24292158
Outcome of elderly patients with circulatory failure.
PMID: 24132383
Document this CPD
One of the biggest problems I encounter with end of life is getting the final decision that we are in fact facing such a situation. I am not in a position to withhold care until indicated by a physician, and this can often put me in a difficult situation. I have had arguments in the past with some staff who feel it is more appropriate to leave a clearly dying patient for resus rather than ring their consultant in the middle of the night…I rang the consultant in the end and got the right decision. However staff with less experience and confidence may not feel able to do this. Should we encourage more emphasis on recognising the warning signs of futility earlier so that we can do the important stuff to let the patient die with the dignity we would all wish for?