Palliative Skills for Frontline Clinicians : Case Vignettes in Everyday Hospital Medicine

Rooted in everyday hospital medicine, __Palliative Skills for Frontline Clinicians__ addresses the challenges of delivering complex care to patients living with serious illnesses. Spanning emergency medicine, internal medicine, surgery and various subspecialties, each chapter reads like a story, comparing usual care with a step-by-step palliative-based approach. This case-based book features a multidisciplinary, palliative-trained authorship, including neurologists, nephrologists, emergency physicians, surgeons, intensivists, and obstetricians. Divided into four parts, Palliative Skills for Frontline Clinicians outlines common clinical scenarios across settings and specialties to highlight unmet needs of patients with potentially terminal illnesses. Each case is broken down into the usual standard approach, and delves into detail regarding different palliative interventions that can be appropriate in those scenarios. These are meant to be practice changing; down to the actual words used to communicate with patients. In addition to the book’s focus on the principles of palliative care and the “art” of treating the patient, approaches to communication with the patient’s families for the best long-term outcomes are discussed. Concise and pragmatic, __Palliative Skills for Frontline Clinicians__ is meant to be practice changing. It provides readers with both a new conceptual framework, as well as actual words to communicate with patients and medication doses for symptom management. It is an invaluable resource for non-palliative trained clinicians who wish to strengthen their palliative care skills. Foreword 6 Preface 8 Acknowledgments 10 Contents 11 Contributors 14 Abbreviations 18 Part I: Emergency Medicine 21 Chapter 1: High-Yield Approach to the ED Goals of Care Conversation 22 Case Introduction 22 Standard Approach 22 Palliative Approach 23 References 28 Chapter 2: A Palliative Approach to End-Stage COPD 29 Case Introduction 29 Usual Approach 30 Palliative Approach 30 Case Continued 32 Usual Approach 32 Palliative Approach 33 Chapter 3: This POLST Makes No Sense 34 Case Introduction 34 Standard Approach 35 Palliative Approach 35 Reference 39 Chapter 4: Treating Pain and Prognosticating in Metastatic Cancer 40 Case Introduction 40 Usual Approach 40 Palliative Approach 41 Usual Approach (Continued) 42 Usual Approach 43 Palliative Approach 43 Chapter 5: Complex Pain Management and Goals of Care in a Debilitated Cancer Patient 46 Case Introduction 46 Usual Approach 46 Palliative Approach 47 References 50 Chapter 6: To Intubate or Not to Intubate: Asking the Right Questions 51 Case Introduction 51 Usual Approach 52 Palliative Approach 52 References 54 Chapter 7: ED Approach to the Hospice Patient 55 Case Introduction 55 Usual Approach 56 Palliative Approach 56 References 59 Part II: Inpatient Medicine 60 Chapter 8: I Can’t Let Him Starve: Artificial Nutrition in Patients with Advanced Dementia 61 Case Introduction 61 Usual Approach 63 Palliative Approach 63 References 65 Chapter 9: Shared Decision-Making in the Setting of a Large Ischemic Stroke 66 Case Introduction 66 Usual Approach 67 Palliative Approach 67 Case Continued – Family Meeting 69 Case Conclusion – Palliative Extubation and Transition to Comfort-Focused Care 72 References 73 Chapter 10: Prognostication and Goals of Care in Advanced Parkinson’s Disease 75 Case Introduction 75 Usual Approach 76 Palliative Approach 76 Setting 79 Perception 79 Invitation 80 Knowledge 81 Emotion 81 Knowledge (Revisited) 81 Summary and Strategy 81 Case Conclusion 82 References 83 Chapter 11: Saying Yes to Aggressive Measures: The Role of Neuropalliative Care in Critically Ill Patients with Potential for Recovery 84 Case Introduction 84 Usual Approach 85 Palliative Approach 85 Case Conclusion 88 References 89 Chapter 12: “I am a Fighter”: Recognizing and Responding to Cancer Metaphors 91 Case Introduction 91 Usual Approach 91 Palliative Approach 92 Violence metaphors in cancer – is it really about fighting? 92 Journey metaphors in cancer – focused on the present and not the outcome 93 Empowerment vs disempowerment – how metaphors define the patient experience 93 Empowerment Metaphors 93 Disempowerment Metaphors 94 Case Continued – Palliative Approach 94 References 97 Chapter 13: “What Does the Awake Ventilated Patient Really Want?”: Shared Decision-Making in the ICU 98 Case Introduction 98 Usual Approach 99 Palliative Approach 99 Case Continued 101 Usual Approach 101 Palliative Approach 102 Chapter 14: A Mother’s Love – Support Despite Disagreeing with Goals of Care 104 Case Introduction 104 Usual Approach 104 Palliative Approach 105 References 109 Chapter 15: End-Stage Renal Disease and Shared Decision-Making Dilemmas 110 Case Introduction 110 Usual Approach 110 Palliative Approach 111 References 114 Chapter 16: Discontinuing Continuous Renal Replacement Therapy in the Intensive Care Unit 115 Case Introduction 115 Usual Approach 116 Palliative Approach 116 Hope/Worry Statements 117 PERSON Framework for Goals of Care 118 Renal Guidelines for Starting, Stopping, and Withholding Dialysis 119 References 120 Chapter 17: Teaching Learners How to Approach Family Decisions as a Process 122 Case Introduction 122 Usual Approach 122 Palliative Approach 123 Part III: Surgery 128 Chapter 18: Trach/PEG Consult in the ICU 129 Case Introduction 129 Usual Approach 129 Palliative Approach 130 Case Conclusion 133 References 134 Chapter 19: Rescinding DNR Orders in the Operating Room 135 Case Introduction 135 Usual Approach 135 Palliative Approach 136 Case Continued 137 References 140 Chapter 20: A Threshold Moment, Preserving Patient Dignity, and the Value of a Time-Limited Trial 142 Case Introduction 142 Usual Approach 142 Palliative Approach 144 Applying the American College of Surgeons “Principles of Palliative Care” and GUIDE [1] Road Map to Breaking Bad News 145 G: Get Ready 145 U: Understand What Your Patient Has Heard Before You Disclose 146 I: Inform, or Disclose, the News Using a One-Sentence Headline 146 D: Deepen Your Connection by Responding to Emotions 146 E: Finally, Equip Your Patient for the Next Steps in Care 147 Case Continued: A Time-Limited Trial 147 Case Conclusion 148 References 149 Chapter 21: Between a Rock and a Hard Place: Anticipating Poor Surgical Outcomes While Honoring Patient Autonomy 150 Case Introduction 150 Usual Approach 150 Palliative Approach 151 Case Continued 153 Usual Approach 154 Palliative Approach 154 References 157 Chapter 22: Surgery for the Hospice Patient: When Is It Appropriate? 158 Case Introduction 158 Usual Approach 158 Palliative Approach 159 Case Continued 159 Usual Approach 159 Palliative Approach 161 Suggested Reading 161 Chapter 23: Nonoperative Approach to Caring for the Ischemic Limb 163 Case Introduction 163 Usual Approach 163 Palliative Approach 164 Chapter 24: Placing a Feeding Tube in a Patient with Dementia 168 Case Introduction 168 Usual Approach 168 Palliative Approach 169 Case Conclusion 171 References 171 Chapter 25: Bowel Obstruction in a Dying Patient: To Operate or Not? 173 Case Introduction 173 Usual Approach 173 Palliative Approach 177 Case Continued 177 Usual Approach 177 Palliative Approach 179 Case Conclusion 180 Takeaway Points 180 References 181 Chapter 26: Geriatric Trauma Decision-Making Based on Functional Outcomes 182 Case Introduction 182 Usual Approach 182 Palliative Approach 184 Part IV: Specialty Medicine 187 Chapter 27: Decision by Surrogates for a Patient with a Psychiatric History 188 Case Introduction 188 Usual Approach 188 Palliative Approach 189 Reference 191 Chapter 28: Palliative Approach to Patients with Concurrent Serious Illness and Substance Use Disorder 192 Case Introduction 192 Usual Approach 192 Palliative Approach 193 Case Continued 193 Case Continued 195 Usual Approach 196 Palliative Approach 196 References 198 Chapter 29: Responding to Spiritual Suffering and Hope During a Goals-of-Care Conversation 199 Introduction 199 Case 1: When There Is Hope for a Miracle 199 Case 2: When Strong Religious Language Enters the Conversation 202 Case 3: When There Is Spiritual Distress 205 References 206 Chapter 30: Trisomy 18: Early and Concurrent Palliative Care Enhances Delivery and Neonatal Planning 207 Case Introduction 207 Usual Approach 208 Palliative Approach 208 Case Conclusion 212 References 213 Chapter 31: Navigating Complex Medical Decision Making in the Pediatric ICU 215 Case Introduction 215 Usual Approach 215 Palliative Approach 216 References 220 Index 221 Front Matter ....Pages i-xxiii Front Matter ....Pages 1-1 High-Yield Approach to the ED Goals of Care Conversation (Bridget Highet)....Pages 3-9 A Palliative Approach to End-Stage COPD (Carter Neugarten, William Burns)....Pages 11-15 This POLST Makes No Sense (Jason K. Bowman, Kei Ouchi)....Pages 17-22 Treating Pain and Prognosticating in Metastatic Cancer (Audrey Tan)....Pages 23-28 Complex Pain Management and Goals of Care in a Debilitated Cancer Patient (Marynell Jelinek)....Pages 29-33 To Intubate or Not to Intubate: Asking the Right Questions (Nitin Ubhayakar)....Pages 35-38 ED Approach to the Hospice Patient (Monique Schaulis)....Pages 39-43 Front Matter ....Pages 45-45 I Can’t Let Him Starve: Artificial Nutrition in Patients with Advanced Dementia (Emily Jean Martin)....Pages 47-51 Shared Decision-Making in the Setting of a Large Ischemic Stroke (Cara Siegel, Jessica Besbris)....Pages 53-61 Prognostication and Goals of Care in Advanced Parkinson’s Disease (Kevin McGehrin, Christina L. Vaughan)....Pages 63-71 Saying Yes to Aggressive Measures: The Role of Neuropalliative Care in Critically Ill Patients with Potential for Recovery (Joel Phillips, Brandon Francis, Justin Voorhees)....Pages 73-79 “I am a Fighter”: Recognizing and Responding to Cancer Metaphors (Rushil Patel, Andrew Epstein)....Pages 81-87 “What Does the Awake Ventilated Patient Really Want?”: Shared Decision-Making in the ICU (Lauren Goodman)....Pages 89-94 A Mother’s Love – Support Despite Disagreeing with Goals of Care (Neha Shah)....Pages 95-100 End-Stage Renal Disease and Shared Decision-Making Dilemmas (Indra D. Daniels)....Pages 101-105 Discontinuing Continuous Renal Replacement Therapy in the Intensive Care Unit (Tamara Rubenzik)....Pages 107-113 Teaching Learners How to Approach Family Decisions as a Process (Alan Garber)....Pages 115-120 Front Matter ....Pages 121-121 Trach/PEG Consult in the ICU (Christine Toevs)....Pages 123-128 Rescinding DNR Orders in the Operating Room (Melissa Red Hoffman)....Pages 129-135 A Threshold Moment, Preserving Patient Dignity, and the Value of a Time-Limited Trial (Pringl Miller)....Pages 137-144 Between a Rock and a Hard Place: Anticipating Poor Surgical Outcomes While Honoring Patient Autonomy (Calista M. Harbaugh, Christopher P. Scally, Daniel B. Hinshaw, Pasithorn A. Suwanabol)....Pages 145-152 Surgery for the Hospice Patient: When Is It Appropriate? (T. Johelen Carleton)....Pages 153-157 Nonoperative Approach to Caring for the Ischemic Limb (Rachel Danczyk, Erika Ketteler)....Pages 159-163 Placing a Feeding Tube in a Patient with Dementia (Jay A. Requarth)....Pages 165-169 Bowel Obstruction in a Dying Patient: To Operate or Not? (Ana Berlin)....Pages 171-179 Geriatric Trauma Decision-Making Based on Functional Outcomes (David Zonies, Andrea K. Nagengast)....Pages 181-185 Front Matter ....Pages 187-187 Decision by Surrogates for a Patient with a Psychiatric History (Jennifer Y. Fung)....Pages 189-192 Palliative Approach to Patients with Concurrent Serious Illness and Substance Use Disorder (Alison Petok, Brooke Worster)....Pages 193-199 Responding to Spiritual Suffering and Hope During a Goals-of-Care Conversation (Evan Wong)....Pages 201-208 Trisomy 18: Early and Concurrent Palliative Care Enhances Delivery and Neonatal Planning (Nathan M. Riley, Ann Marie Case, Josephine Amory, Krishelle Marc-Aurele)....Pages 209-216 Navigating Complex Medical Decision Making in the Pediatric ICU (Jaime Jump)....Pages 217-222 Back Matter ....Pages 223-227