Episode 8: Palliative care with Jessica McFarlin (part 2)

The second part of our look at a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects, with neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD).

See Part 1 here.

Takeaway lessons

  1. Useful phrase: “Can I tell you what to expect during the dying time?”
    1. Discuss the possibility of secretions, etc. Use glycopyrrolate.
  2. Use opioids if you expect dyspnea, otherwise not always needed. Can try a pressure support trial on the ventilator to get a sense for tachypnea.
  3. Let both family and the nurse know what to expect after extubation.
  4. Other than the occasional incidence of troubling myoclonus with fentanyl, and restrictions on its use outside of the ICU in many centers, all opioids are probably equally good for end-of-life care. Consider hydromorphone in renal patients.
  5. In general, stop tube feeds at the end of life, and stop trying to ensure full nutrition, but do offer food and drink for comfort. Dying tends to limit hunger and caloric needs anyhow. Stop IV fluids as well.
  6. When families invoke a “miracle scenario,” reframe by asking what a miracle might look like for them, or raise the possibility that the miracle won’t be survival, but another outcome such as surviving until the rest of the family arrives, or being comfortable and pain-free during the dying process.
    1. Use “I wish [it would work]” statements to express empathy and a shared perspective, while maintaining a fact-based reality. Stop there and don’t wade into details.
    2. Turn miracles into concrete plans by establishing a time trial with a deadline, with clear markers for what success will look like.

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