Palliative Care Considerations for Older ED Patients in the age of COVID-19
June 1, 2020
Thank you to all who attended this webinar on June 1, 2020. Below, we have made the webinar recording, chat notes, and presentation slides available for all those interested in learning more about palliative care considerations for older adults during this pandemic and beyond.
Main Learning Points
Dr. Tammie Quest
Dr. Quest discussed the four types of critical conversations in serious illness: breaking bad news; prognostication; goals of care conversations; and discussion of life-sustaining interventions. She emphasised that with COVID, there is an enhanced uncertainty factor because we have limited experience, but that almost certainly some prognostic weight relates to pre-morbid functional status or frailty. She discussed the components of a standard goals of care conversation: confirm illness understanding; elicit goals of care; recommend treatments consistent with goals of care; and establish a plan and confirm it. She advised to avoid therapeutic nihilism and our personal cognitive biases (15% of older patients doing poorly; but 85% survive.)
Dr. Erin O'Connor
Dr. O’Connor focussed on common symptom complexes and their management: dyspnea; nausea; airway secretions; agitation. She emphasised the importance of reviewing the medication list (to ensure no withdrawal or unintended consequences (e.g. Parkinson’s meds) and of determining if the patient is imminently dying or just symptomatic, within the context of uncertainty about diagnosis or diagnoses that may exist.
Dr. Martine Sanon
Dr. Sanon re-visited the common geriatric concept that “age is just a number” and that it doesn’t tell us much about the reality of a given patient – from robust to frail; health to polymorbid. Based on the wide experience of very will COVID patients at Sinai New York she suggested some strategies for decision-making: make sure you have the correct decision-maker; goals of care; determine wishes re: intubation, resuscitation; facilitate real-time conversations using video or phone; develop a treatment plan. She then described the strategies they used at their hospital to develop a help line for ED clinician; and subsequently to embed palliative care clinicians in the ED.
- To present evolving ED-based models for palliative care.
- To provide a framework for ED-based goals of care conversations that elicit patient goals and values, explore illness understanding, address prognosis, and make recommendations.
- To review symptom management for older adults with COVID-19.
- To consider strategies to enhance access to palliative care in the ED.
Don Melady, MD
Tammie Quest, MD
Professor and Chief, Division of Palliative Medicine
Professor, Department of Emergency Medicine
Director, Emory Palliative Care Center
Martine Sanon, MD
Associate Professor, Department of Geriatrics and Palliative Medicine
Icahn School of Medicine
Mount Sinai, New York
Erin O’Connor MSc MD
Divisions of Emergency Medicine and Palliative Medicine
University of Toronto
Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.