Conversations in the Emergency Room

Niamh Collins FRCEM FJFICMI Consultant in Emergency Medicine Connolly Hospital Blanchardstown

Emergency Medicine is….. a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural disorders.

Emergency Medicine Staff want to do their best for their patients

Challenges Patient diversity Reversibility - Injury or Illness Time imperative Limited information

Conversations relate directly to these challenges

Urgency: preserving life while gathering information

Medical Council: There is no obligation to start or continue a treatment that is futile or disproportionately burdensome, even if it may prolong life

Burden verses the benefit of treatment

Withholding (passive) and withdrawing (active) treatment are ethically equal

We must never stop caring for our patients

It is the treatment that is futile, never the patient

“Do everything that should be done rather than everything that could be done”

Conversations with the patient Fundamental: respect autonomy Intimidating/overwhelming to discuss possibility of death People not empowered in advance to make an informed choice Communication is severely impaired by injury or illness

Life Sustaining Treatments

Level 1

Level 2

Level 3

Haemodynamic support

Giving fluids or blood through a small drip or intravenous line into a vein. Inserting the line is relatively safe, simple and involves minimal discomfort.

Giving powerful medications (called inotropes or vasopressors) to improve blood supply to the body’s organs into very big veins in the neck, chest or groin. Inserting central lines is complex, risky and uncomfortable.

Inserting a special pump called an Intra-aortic balloon pump into the main blood vessel of the body (the aorta). It is a very complex and specialised procedure in specialised centres. You must lie flat in bed attached to a machine.

Respiratory

Oxygen therapy.

Non-invasive ventilation:

Invasive ventilation:

(breathing) support

This is given through a plastic mask. It is not painful but the mask can be noisy or irritating. It is a safe treatment which helps the problem of too little oxygen.

Feeding

Fluids only

This involves a tight mask sitting over the person’s mouth and nose. It is connected to a medium sized machine that supports the person’s breathing. It is more uncomfortable than a normal oxygen mask. Some people feel claustrophobic or the mask hurts their nose or face. The person must be conscious. Naso-gastric (NG) feeding tube. A thin piece of plastic tubing runs through the nose, throat and food pipe (oesophagus) into the stomach. Inserting the tube can be uncomfortable, as is the feeling of the plastic at the back of the mouth. Food is given as a liquid continuously.

A breathing tube (1 cm wide and 25cm long) is placed in the mouth, throat and sits inside the lungs. A machine supports the person’s breathing. The strong medications needed to put the tube in can cause complications. Sometimes sedating or paralysing medication is used to reduce the discomfort. A PEG tube (percutaneous endoscopic gastroscopy).A small hole is made in the stomach wall that connects with a small hole in the skin of the abdomen. A plastic feeding tube goes directly into the stomach. Food is given as a liquid.

None

Treatment of an infection with a medication taken either by mouth or through a peripheral line.

Treatment of an infection with a medication given through a central line.

Renal Support

Monitoring blood tests

Urinary catheter A soft plastic tube is placed in the bladder and urine drains into a bag. The amount of urine collected is measured Inserting the tube can be embarrassing and uncomfortable. The bag is placed either by your leg or at the side of the bed.

Dialysis A large machine does the work of the kidneys. A very large intravenous line is inserted into a vein in the neck, chest or groin. Blood is removed from the body, filtered and returned to the body. If the person is very sick then the machine works all the time.

Surgery

No surgery, even if that means that there is a very high chance of dying.

Have surgery if there is a high chance of recovery and a low risk of dying.

Have surgery even if the risk of dying is high, because that’s the best way to cure the condition.

Anti-microbial therapy

Total Parenteral Nutrition Liquid food is given into a large central line in the neck or chest.

Treatments that promote comfort Pain relief

Level 1

Level 2

Level 3

Simple pain relief than has a mild effect on pain but causes little side effects.

A sufficient dose of a strong pain killer that reduces but does not eliminate pain. It can have moderate side effects.

Enough pain relief to reduce the pain. The side effects can affect your ability to breath or your awareness of your surroundings.

Sedation

None, even if your condition or treatment is distressing.

Some sedation to help relieve anxiety or discomfort but you still have awareness of your surroundings.

Spiritual support

No professional support, just our own friends and family.

The presence of someone of your own faith to be with you when critically ill.

Enough sedation to relieve all anxiety and discomfort. It can cause extreme drowsiness and no awareness of your surroundings. A detailed plan of your spiritual needs to be given to your care-givers when critically ill.

Physical

Physical environment is less important. Your preference is having highly skilled staff and resources so that you are given every opportunity to recover.

An attractive quiet area with space for family and friends. Your preference is that your comfort and dignity are maintained even if that results in less investigations or procedures.

environment

You would like to be treated as close to home as possible, even if that means that you do not avail of the full expertise of a hospital in managing your illness.

Conversations with family Need to determine the patient’s wishes from the family (not what the family want) Knowledge of medical illnesses, frailty and quality of life Discuss what we hope the treatment will do Organ donation wishes

Conversations with colleagues Good practice – shared decision making Great fear about making the wrong decision; default to be “actively doing”, rather than “actively caring” Insufficient training in almost all medical specialties on EOL care

Emergency Departments and Emergency Medicine – perpetually undervalued in Ireland

Key Facts: Emergency Medicine Attendances: 1.2 million annually Medical Workforce Consultant: 73 total. [1 per 16,400 patients], Need: 180 (short-term), 240 (long–term) Non-consultant Doctors: Registrar/Specialist Registrar: 202, SHO: 204, Intern: 11 Department Design: Emergency Department Task Force (2007); 7 out of 18 ED’s reviewed were “unfit for purpose” and most of the remainder required significant infrastructural improvement. Degree of over-crowding: Nationally, there are ~300 admitted patients “boarding” in the ED each day waiting for an available bed on the ward.

Overcrowding - may affect patients in neighbouring cubicles

Suggestions/Recommendations •

Public to be as informed as possible & to communicate their wishes; Think Ahead, Health Insurance forms, talking, residential care notes

•

Assisted Decision Making (Capacity) Bill to be enacted

•

Improved EOL education (undergraduates) and EOL exam topic (post-graduates)

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Better senior staffing levels to enable best practice

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Infrastructure improvements (IAEM “Standards for Emergency Department Design and Specification 2007”, Hospice Friendly Hospitals “Design and Dignity 2008” guide.

Thank you

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