End-of-Life Issues for Emergency Nurses

Chapter 17 End-of-Life Issues for Emergency Nurses



Emergency clinicians are frequently involved with deaths that occur suddenly and unexpectedly as a result of motor vehicle crashes, penetrating trauma, massive cerebrovascular events, or myocardial infarction. With today’s medical advances in treating chronic diseases, emergency nurses are just as likely to care for a significant number of patients with terminal illnesses for whom death is expected. As illness progresses, visits to the emergency department (ED) often become more frequent. Nurses play a unique and vital role in caring for—and advocating on behalf of—these patients and their families, as the focus of intervention shifts from curative to palliative. The end of life is defined as the period in which:



The trend toward offering patients in-home palliative care earlier in the end-of-life process is having an impact on how patients die in today’s society. Palliative care focuses on the physical, psychological, social, spiritual, and existential needs of the patient and family. The goal of palliative care is to help the patient achieve the best quality of life by relieving uncomfortable symptoms while respecting religious and cultural practices.1 Palliative care is often provided through hospice services or palliative care services. Nonetheless, emergency providers still have many opportunities to improve care by helping to provide a dignified end of life for patients and their families and supporting cultural and religious practices.2



End-of-Life Decisions



Advance Directives


An advance directive is a means of documenting an individual’s wishes regarding future health care if he or she is unable to make medical decisions because of reasons such as coma or cognitive impairment.



Statements made in an advance directive typically reflect the values and beliefs of the individual and may change over time as an illness progresses or an emergency arises. Discussion and formal documentation before such a crisis is more likely to ensure that a patient’s wishes are respected and carried out. Two possible components of an advance directive are the following:



Living wills and health care proxies are flexible documents that can be changed easily or revoked. This can be done in a variety of ways, including by simply telling a health care provider. In the emergency setting, emergency providers must exercise care to make sure the latest version of these documents is available.



The Patient Self-Determination Act of 1990 is a federal law that requires all health care agencies that receive federal funding to recognize advance directives. Under the law, hospitals must do the following:5



Standards may differ from state to state and from institution to institution. Patients are never required to have advance directives, and facilities may not discriminate against patients who have or do not have one.



If a patient does not have an advance directive and is unable to make his or her own medical decisions, then clinicians must seek guidance from a spouse, adult child, parent, or friend or they must pursue appointment of a legal guardian.



Table 17-1 provides a list of Internet resources related to advance directives.


TABLE 17-1 INTERNET RESOURCES RELATED TO ADVANCE DIRECTIVES





















ORGANIZATION OR GROUP INTERNET ADDRESS
American Association of Retired Persons http://www.aarp.org/index.html
Aging with Dignity—Five Wishes http://www.agingwithdignity.org/5wishes.html
American Bar Association (ABA Network) http://www.abanet.org/home.cfm
American Medical Association http://www.ama-assn.org
Compassion & Choices http://www.compassionandchoices.org



Out-of-Hospital Do Not Resuscitate Orders


Many states in the U.S. have passed legislation allowing out-of-hospital DNR orders. These laws go by a variety of names, including portable DNR, community-based DNR, and physician order for life-sustaining treatment (POLST). These laws require the following:



If an individual with an out-of-hospital DNR order experiences a cardiac or respiratory arrest, emergency medical services personnel should not initiate CPR. However, they can provide the following:







Some states limit access to out-of-hospital DNR orders to patients who are terminally ill or elderly, whereas other states make them available to any competent adult.


To be valid, an out-of-hospital DNR order requires the health care provider’s signature and the patient’s or surrogate’s signature.


To avoid potential confusion, patients should have a copy of the original order and some form of wearable identification such as a medical alert bracelet.


Most states include a provision allowing emergency medical services personnel to perform CPR if the family persistently and strongly requests it, even if the patient has an out-of-hospital DNR order. However, in these difficult situations, emergency medical services personnel are trained to counsel families to forgo CPR.


Ideally, medical facilities will have a policy that defines the circumstances under which an out-of-hospital DNR order will be honored within the health care facility. These policies should address care of the person with an out-of-hospital DNR in the ED, clinic, or inpatient setting. In addition, discussion regarding out-of-hospital DNR orders should be part of the physician and nursing discharge plan for all appropriate patients.


Many states are working to make out-of-hospital DNR orders the standard for nursing homes and other community-based care facilities so that emergency medical services personnel responding to these facilities can honor DNR requests.


Importantly, an out-of-hospital DNR order is not an advance directive. The out-of-hospital DNR order is a physician’s order to withhold life-sustaining therapy, and it requires a patient’s or surrogate’s signature as evidence that informed consent occurred, similar to consent for a surgical procedure. Table 17-2 summarizes specific differences between advance directives, institution-based DNR orders, and out-of-hospital DNR orders.




Common Medical Emergencies at the End of Life


Patients with a terminal illness may present to the ED with a problem that requires rapid intervention. Examples include conditions such as uncontrolled pain, delirium, hemorrhage, bowel obstruction, and spinal cord compression. Emergency personnel should attempt to determine the wishes of the patient and family as well as explore other possible alternatives.



Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on End-of-Life Issues for Emergency Nurses

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