As you know, my motto is maximally aggressive care, ALWAYS! Maximally aggressive curative care and maximally aggressive palliative care. I did a podcast episode on critical care palliation a year or so ago.

At this year's EMCrit Conference, Ashley Shreves gave the ultimate lecture on the topic. Twenty minutes jam-packed with goodness.

* The End-of-Life and Palliation Education Resource Center

A listener, Don Zweig, wrote with this summary:

* We (as in ED docs) in general deal with End of Life Care and palliative care situations poorly.

* Our job as physician is to understand the family goals and values and then give a professional recommendation- it is not to give a menu--they have no medical knowledge to reasonably make this choice.

* Three things we should never say:

*  "Do you want us to do everything?"  Of course they do, but if you offer "everything" who wouldn't want mom to get everything? Could they say…."no, whatever you do , don't do everything for mom!" This also makes the family feel that everything (whatever that entails) is reasonable or possible. Instead use the 'Pal Care' approach and say, "What would be most important to you and your mom now?"  On the basis of what you hear make a reasoned professional recommendation.

* "Do you want us to resuscitate her?"  This implies that we think it is possible or reasonable to do this!  Since you ask this it must be reasonable.  "You can just bring her back?  Great, go ahead!" Use natural death language.  So it sounds like your mom would want a natural death?  When her heart stops we will not interfere with that process

* " I am so sorry, there is nothing more we can do"  There is a lot that can be done and it involves maximizing comfort and minimizing suffering. They need palliative care or hospice.    So call a consult and give palliative meds.

* Try to get private room and take them off the monitor!  There is no place for monitor in the dying patient for which you are providing comfort care.

* Treat discomfort with morphine or dilaudid in very small doses.  Double every 15 minutes until decreased suffering.

Addendum

This amazing post on the blog Expensive Care is a must read on the topic of the ethics of CPR

Treating Pain in Palliative Patients

Survival of old intubated folks (J Am Geriat Soc 2018)

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