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Beginning Goals of Care Discussions in the Emergency Department: A Case Study in Mitigating Complicated Grief (SA306C)
Abstract   Open access   Peer reviewed

Beginning Goals of Care Discussions in the Emergency Department: A Case Study in Mitigating Complicated Grief (SA306C)

Daniel G. Miller
Journal of pain and symptom management, Vol.65(5), pp.e530-e530
05/2023
DOI: 10.1016/j.jpainsymman.2023.02.040
url
https://doi.org/10.1016/j.jpainsymman.2023.02.040View
Published (Version of record) Open Access

Abstract

1. Recognize elements of an emergency department (ED) patient presentation that indicate an urgent need for goals of care discussion. 2. Identify certain elements of goals of care discussion that can be helpfully reviewed in advance of having complete diagnostic and prognostic information. Many moribund patients enter our healthcare system through the ED. While complete diagnostic and prognostic data are typically not available during an ED encounter, emergency physicians (EPs) can identify a significant proportion of patients at high risk of death. This offers an opportunity to elicit information that can prove valuable in later goals of care discussions (GoCDs). We present a case where information gathered in the ED aided later GoCDs and mitigated a family's complicated grief. A man with recently diagnosed lung cancer presented to our ED, unaccompanied by family, with symptoms of spinal cord compression and was diagnosed with acute L3 spinal cord compression, encasement of his mediastinal vessels, and hyponatremia. Recognizing potential for poor prognosis and a high risk of delirium, the EP began a GoCD while the patient was lucid, learning that the patient's primary goal of treatment was to be able to care for his wife. Worried that his wife's neuropsychiatric condition would make it too burdensome for her to serve as his surrogate, the patient requested that his son be his surrogate decision maker if needed. The patient's hospital course involved multiple complications including delirium, precluding his participation in further GoCDs. Our case presentation will demonstrate how certain elements of GoCD obtained early in the hospital course were able to play a helpful and prominent role in GoCDs after the patient lost capacity to make his own decisions. This will serve as an example of how beginning GoCDs early in the hospital course, before complete prognostic information is available, can benefit appropriately selected patients.

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