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.