Mythbusting

Chronic opiate use leads to worse surgical outcomes

No surprises here. This study looks at outcomes after major elective abdominal surgery ~500 patients on chronic opiates vs ~1900 opioid naive patients from a single center from 2008-2014.

9.2% higher costs, 12.4% longer LOS (5.9 vs 5.2 days), higher complication rate (20% vs 16%), more readmits (10% vs 6%), without a difference to discharge destination (home, SNF, etc).

On one hand, you play the hand youre given – you help the patient the best way you can. But, what if that means you detox them first? It will be interesting to see if some providers go to that extreme. Especially if they (or hospitals) are not reimbursed at a higher rate to take on the added risk / LOS / bounceback rates. I know of orthopaedics refusing surgery based on a patients weight – I can envision a scenario in which the (currently) heavily-stigmatized opiate addicted patient is deemed unfit for non-emergent surgery so that facilities and providers retain their “5 star” ratings for various non-emergent surgical procedures to gain the insurance dollars of the “educated consumer”.

Sigh. This is quite the ethical pickle.

Next question – does this spill into EM? Should we withhold 1-2 doses of opiates for fear of worse outcomes? A perforated viscous seems like a good indication for opiates if ever there was one.

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"Palliative" is not a dirty word, Improving Outcomes

“The Treatment of Pain is Very Important.”

Back to pain being the 5th vital sign, or so this study may have us believe. This study included an independent investigator essentially sneaking into the patient room to tell half the patients that “the treatment of pain is very important and be sure to tell the staff when you have pain.”

77.6% of the control vs 88.8% of the intervention group reported being provided with the above “pain advice” and the intervention group had an absolute and relative increase in satisfaction of 6.3% vs 14.2%, respectively. 91.3% of patients who were “very satisfied” had received this advice vs 76.3% of patients who were not “very satisfied” having received “pain advice.”

I think that ultimately, the aforementioned increase in patient satisfaction goes with giving clear instructions, and being clear with your projected management and expectations. I imagine that having a third party (such as Dr McDreamy) come over and say, “the treatment of pain is very important and be sure to tell the staff when you have pain,” will undoubtedly boost patient satisfaction. Likewise, I also question if it buys a bit (too much?) into “pain is the 5th vital sign” that got us into our current opiate frenzy in the first place. Regardless, there is potential for this to be a useful word choice in the quest for improved Press Ganey scores.

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"Palliative" is not a dirty word, Improving Outcomes

Remember Palliative Care for Dementia!

A 78 year old patient is brought to the ED for the 4th time in 3 months for “not acting quite right.” Previously, the patient has been admitted for a urinary tract infection twice, and once for altered mental status. The patient seems friendly, answers many questions smiling, chuckling, and downplaying their symptoms. In fact, the patient seemingly can not explain why they are in the ED, and seem oblivious to there being anything wrong. The family reports that the patient is not eating as much as they used to, and that the patient had wandered out of the house and gotten lost twice last week. One family member admits that things seem to not be getting better despite their previous admissions, while another eagerly requests to “check the urine.”

An Australian study looked at 5261 patients who died with dementia over a 2 year period, with 2685 comparative patients without dementia who died with conditions amenable to palliative care. More than 70% of both groups visited an ED in the last year of life. Only 6% of the dementia cohort vs 26% of the non-dementia cohort were involved in palliative care. In the last year of life, those that did not receive palliative care were 1.4 times more likely to have a repeat visit to the ED within the next 3 months, and 6.7 times more likely to visit the ED in the weeks preceding death.

Here is an intervention that makes patients and family happier, has been proven to extend life, die with dignity, and save hospital visits & admissions. Why are we not doing this more?

So what can palliative care provide? Good question. So I asked a palliative care doc (@palliativedocto) what they thought. Their take:

I would make sure the family, and patient if it’s early dementia, understand the symptoms and progression of dementia, environmental adaptions for a demented family member, the medications that can be used to help with symptom management, the use of feeding tubes, and the importance of completing an advance directive if that has not been done. I would, as you suggest, eliminate any unnecessary medications, being cognizant of the stage of the dementia. Hospice should be brought up, if not for now, for the future. And finally, have social work see the family for help with everything they need, including any financial benefits they’re eligible for, as well as the expected crises that will surely ensure.”

Doesn’t that sound awful? Provider’s educating patients & family on a chronic, irreversible disease. Such a terrible thing! This makes for a great situation to place the patient in the observation unit, set the wheels in monitor for palliative care to see the family & patient, and save a visit to the ED.

Palliative is not a dirty word.

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"Palliative" is not a dirty word, Mythbusting

Peacefully Passing in the ED.

I’ve often half-jokingly stated that I believe we treat our pets better than our family at the end of life.  Our beloved Fido dies after a run on the beach, a steak dinner, and with a slug of morphine.  Grandma?  She gets intubated without pain medication, gags a bit, and likely dies in significant distress.

We can make this process more peaceful.  There is a significant movement for emergency medicine to OWN palliative care.  We need to recognize when heroic efforts will go for naught (1 year mortality for a patient >85 years old admitted to the ICU is 97%).  We can be soothing.  We can start Fentanyl drips.  We can add on anti-secretory agents.  We can add on a bit of anxiolytics.

As per a recent study, according to the family of the deceased, what factors were associated with the perception of peaceful death?  Adequate personal attention.  Adequate personal care.  Family finds enough nurses available.  And a you can make a phone call.

Religious affiliation reflected in end-of-life decision making has been associated with the perception of a peaceful passing.  Simply offering a chaplain to come in often times is soothing to the family and provides a sense of closure.  There is something about the end of a loved ones life that brings out an inner spirituality to both atheists and believers.  This is so simple to do!  If the RN asked me if they could page the chaplain for my dying patient, I would be embarrassed I had yet to do it myself.  It is one of few things that we all could do that has been shown to influence a family members opinion that their loved one passed peacefully.

Next time it appears futile, and the end of life discussion has been had, offer a chaplain.  The discussion and reality is never going to be easy for the family.  Let’s make an honest attempt to make it less difficult.  Let’s turn off the monitor, turn on the Fentanyl drip, load the patient with hyoscine, and get the chaplain on board.

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When do people with dementia die peacefully? An analysis of data collected prospectively in long-term care settings PMID:24292158

Outcome of elderly patients with circulatory failure. PMID: 24132383

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