This case is thefourth in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.
Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).
Why it Matters
Elderly patients requiring resuscitation are frequently encountered in the ED. When patients are non-communicative, close family members are regularly required to act as substitute decision makers and represent their family member’s wishes. Engaging and communicating effectively with SDMs in end-of-life and goals-of-care discussions is necessary to provide the most appropriate care for the elderly patient. This case gives the opportunity to learn and enhance these skills.
The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”
An 89-year-old patient is brought in to the ED by ambulance from their nursing home. Staff found her unresponsive and hypotensive at morning handover. She had been treated for UTI by her family physician over the last few days. Participants identify severe sepsis and realize that critical care interventions may be inappropriate. This should prompt a goals of care discussion including potential for initiating end-of-life care.
This case is written by Dr. Alexandra Stefan. Dr. Stefan is an emergency medicine physician and the Postgraduate Site Director for Emergency Medicine at Sunnybrook Health Sciences Centre in Toronto. She is also an assistant professor in the Division of Emergency Medicine at the University of Toronto. Her areas of interest are postgraduate medical education, simulation (has completed the Harvard Centre for Medical Simulation training course) and global health education (has participated in teaching trips with Toronto Addis Ababa Academic Collaboration).
Why it Matters
Emergency medicine training is often focused on the many interventions we can make when a patient arrives in distress. This case highlights that sometimes, one of the most important interventions is to determine a patient’s goals of care. It specifically highlights:
The importance of pain management as a part of end of life care
The need to speak clearly and without medical jargon to establish a patient’s wishes
That goals of care conversations often happen in the ED through a substitute decision maker, rather than with the patient directly.
“A 72 year old man from home with acute shortness of breath has just been placed in the resuscitation room. He has a history of lung cancer and is on 2L home oxygen. His daughter Cindy called 911 because he has been getting worse since this morning. He just finished a course of antibiotics for presumed pneumonia. He is on hydromorph contin and prochlorperazine. No allergies. Here is his most recent oncology clinic note.”
A 72-year old male with small cell lung cancer and bony metastases presents with acute shortness of breath. Curative treatment has been stopped and palliative care assessment is pending. He is on home oxygen and has come to the ED as his symptoms could not be controlled at home.
The patient initially improves with oxygen and pain control. He is too confused to engage in discussion about advanced directives. No previous advanced directives or level of care have been documented but, Cindy, the patient’s daughter is available to act as decision maker. She will have a number of questions about her father’s care.
The patient’s respiratory status will deteriorate. Cindy will confirm her father’s wish for comfort measures, to be started by the treating team.