Case Presentation:

Case Presentation:

EMS is called to the home of a 62-year-old male with history of metastatic lung cancer who is on hospice. The patient’s wife notes that he has developed increasing confusion and shortness of breath since the middle of the night. He has been getting weaker and eating less over the past week. Upon assessment, the patient is lethargic with tachypnea, increased work of breathing, and delayed capillary refill. Initial vital signs are Temp 101.4 F, HR 132, BP 82/48, RR 28, O2 Sat 78% on RA.

Hospice is an insurance service benefit as well as a philosophy of care. It provides care focusing on the relief of suffering, when cure is not an option and anticipated life expectancy is 6 months or less, by addressing physical, psychosocial and spiritual needs. Hospice care can be delivered wherever a patient resides (at home, in a nursing facility, at a board and care, and even inpatient at an acute care hospital).

Hospice provides many resources for end-of-life care including the following:

Medications for symptom control – Commonly referred to as a “comfort kit” or “emergency kit,” patients and their families are provided a supply of medications to keep at home to treat pain, dyspnea, anxiety/agitation, nausea, increased secretions, and constipation. These are often kept in the refrigerator to make them easily retrievable.

Sample Hospice Agency Comfort Kit

Symptom Medication Dose Instruction Quantity
Pain and/or Dyspnea Morphine IR 15mg tablet ½ tab q1h PO / SL / PR prn 20
Agitated Delirium Haloperidol 5mg tablet ½ tab q3h PO / SL / PR prn 10
Nausea and Vomiting Haloperidol 5mg tablet ½ tab q3h PO / SL / PR prn 10
Anxiety Lorazepam 0.5mg tablet ½ tab q4h PO / SL / PR prn 20
Seizure Lorazepam 1mg tablet 4 tabs q4h PO / SL / PR prn 20
Fever Acetaminophen 650mg suppository 1 supp q4h PR prn 6
Constipation Bisacodyl 10mg suppository 1 supp q72h PR prn 3

IR – immediate release; PO – orally; SL – sublingual; PR per rectum; prn – pro re nata – as needed

Medical equipment – This includes durable products such as a hospital bed, wheelchair, bedside commode, or oxygen supplies; and disposable products such as bandages, incontinence supplies, and gloves.

Interdisciplinary care team – A comprehensive medical team consisting of a hospice physician, nurse, social worker, home health aide, and chaplain to coordinate and provide services. The frequency of care team member visits is dependent upon patient/family needs. Interdisciplinary care teams continue to provide bereavement support to loved ones after a patient’s death.

24/7 phone line – Though hospices general do not provide 24/7 care at the bedside, they are always reachable over the phone and, in many cases, have the ability to send someone to the bedside urgently to address concerns.

Treatment goals of patients on hospice are focused on preserving dignity and quality of life, rather than enduring burdensome treatments for medical conditions.

The first step is identifying the concern, which can be an uncontrolled symptom or caregiver anxiety. Overall, goals of care should be established with the patient and/or family members or caregivers. An empathetic approach to this information gathering step followed by a statement of reassurance of the support you will provide is recommended:

“I can’t imagine how scary it must have been to find your loved one in distress… We are here for you and will create a plan together.”

Next, check to see if a POLST is available to confirm the patient’s goals of care. This document should be used to verify that the patient and/or family still prefer to pursue comfort-focused care.

Avoid misleading phrases like:

“Do you want us to do everything?”

Lastly, coordinate with the patient’s hospice agency regarding a treatment plan. Their 24/7 phone number can usually be found on the comfort medication prescription bottles if unable to be located elsewhere. They will be able to guide you and the patient/family regarding what resources can be available to the patient at home.

When you evaluate the patient you find the patient is febrile, has bilateral rhonchorous breath sounds without wheezing or stridor, and no signs of volume overload. Upon speaking with the patient’s wife, she tells you how she has been scared to administer any of his comfort medications out of fear of adverse effects. A POLST signed by the patient and his physician is found on the refrigerator door and is checked Do Not Attempt Resuscitation/DNR and Comfort-Focused Treatment. The patient’s wife mentions she did not think to call the hospice agency since she did not know if they would be available at this hour. You recommend collaborating with the hospice agency regarding a plan.

The patient likely has sepsis from pneumonia. His provider impressions are Sepsis (SEPS), Shock (SHOK) and Respiratory Distress / Other (RDOT). You prepare to treat the patient in accordance with TP-1204, Fever/Sepsis, TP-1207, Shock/Hypotension and TP-1237, Respiratory Distress.

You express your concern that the patient has sepsis likely due to pneumonia.  The wife becomes emotional and acknowledges that he may be near the end of his life and she knew this may be coming. The hospice agency has been contacted and is available to discuss goals of care with the wife and patient.

You provide a report to the hospice liaison, who is thankful to receive this information.  She advises that based on the goals of care discussion with the wife and patient, their goal is to optimize comfort and to allow death at home.  She states that IV access and fluids are not necessary to provide symptom management, and would be overly aggressive for this dying patient whose goal is comfort. She recommends starting the patient on 3L of oxygen via nasal canula and having the wife give the patient morphine 10mg SL from his medication kit. Additionally, she talks with the wife, providing her with further emotional support and arranges for one of their nurses to come to the home within the next hour.

You confirm with the wife and patient that they want to follow this plan and do not want hospital transport.

You make Base Contact to discuss the declination of further care as per Ref. No. 834, Patient Refusal of Treatment/Transport and Treat and Release at Scene and Ref. No. 815, Honoring Prehospital Do Not Resuscitate (DNR) Orders and as is required by Ref. No. 1200.2 for the Provider Impression, Shock (SHOK).  Per Ref. No 815, base contact is required for any advanced health care directive other than withholding resuscitation. The patient is too weak to talk on the phone but the wife (patient’s decision maker) is able to convey an understanding of the options and reasons for declining more aggressive care and transport to the Base.  The Base confirms that the wife understands that non-treatment and transport will likely result in death at home which is in accordance with the patient’s and family wishes.  This patient has abnormal vital signs and meets Base Contact requirements, so typically non-transport would require AMA by policy (Ref. No. 834), but per Ref. No. 815, POLST patients requesting only comfort-focused care “should not be transported unless their comfort needs cannot be met on scene and transport is in accordance with their wishes”.  Because the patient has a signed POLST detailing wishes for comfort-focused care, non-transport is appropriate and in line with the patient’s goals of care.

After Base Contact, the encounter can be documented as Assess, Treat and Release with description of comfort-focused care in the narrative in accordance with the POLST.

You are able to assist with starting the patient on the portable oxygen available at his home. The wife is able to administer the morphine from the patient’s home kit. A few minutes after administration of the medication, the patient’s breathing starts to ease. The wife expresses her gratefulness for your support.

Upon the hospice nurse’s arrival to the patient’s home, his work of breathing has significantly improved but he is still having some anxiety so she administers additional medications for comfort. The hospice nurse is able to spend time with the wife educating her about the dying process, which is expected to progress over the next hours to days, as well as instruct her on the frequency and doses of medications to provide. The following day, the hospice agency receives another phone call from the wife stating the medications do not seem effective. The patient is urgently re-evaluated by the hospice team and, based on his escalating symptom needs, is started on Continuous Care (where a hospice nurse is stationed at the patient’s home 24/7). He dies peacefully two days later. Hospice continues to provide periodic check-ins for bereavement support with his wife and family.

Case Presentation:

EMS providers respond to the home of 87-year-old female with history of Alzheimer’s disease who is on hospice. The patient’s son notes that he found the patient on the ground in pain with a deformity on her wrist after hearing her fall from the other room. He states that she has become more unsteady with her walker as of late. Upon arrival, the patient is uncomfortable and making incomprehensible noises. She does not have any evidence of head trauma and her right wrist has a visible deformity with adequate distal perfusion. Initial vital signs are HR 110, BP 158/96, RR 16, O2 Sat 99% on RA.

The patient has an obvious deformity to her wrist with a likely fracture. Her provider impression is Traumatic Injury (TRMA), and as according to TP-1244, Traumatic Injury for isolated extremity injury, you splint the injury for comfort. You administer Fentanyl 50mcg (1mL) slow IV push for pain management. The son has called the hospice agency to notify them and ask for advice.

You provide information to the hospice liaison at the son’s request. They recommend transport the patient to the emergency department (ED) to receive x-rays and more definitive management for the injury as this will be difficult to coordinate from home.

You transport the patient to the emergency department and her son follows.

You provide report to the ED which includes her medical history, her POLST, and contact information for her hospice agency. They are happy to hear that the hospice agency has already been notified. Work-up reveals a displaced and angulated distal radius fracture. The patient is anesthetized using a hematoma block, her wrist is reduced to anatomical configuration to reduce swelling and pain, and she is re-splinted. The ED updates the hospice agency and the patient is transported back home to continue on hospice.

Learning Points

  1. When responding to patients on hospice care, check for a POLST to assist with validating treatment goals.
  2. All hospice agencies have a phone number they can be reached at 24/7. Involve them as well as the family in the patient’s management plan.
  1. A supportive presence can help allay family fears and worries when a patient enters the active dying process.
  1. Though many symptoms can be managed at home by services provided by hospice, there are some conditions (e.g., uncontrollable hemorrhage, angulated fractures, etc.) that may require hospital transport to optimize the patient’s goals of care.

Author: Jaskaran Singh, MD