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This month we are looking at advance directives, DNR orders, living wills, MOST, and POLST forms. If you don’t understand what all of those are, then you should definitely listen! I am joined by Drs. Ferdinando Mirarchi and Marie-Carmelle Elie who are researchers and leaders in the realm of palliative care and advance care planning.

Unfortunately, advance care planning is complicated by regional differences, policies, and differing scopes of definitions for orders. Listen for more information and ideas.

This episode is timed to coincide near April 16th which is National Healthcare Decisions Day! This exists (per their website here)  “to inspire, educate, and empower the public and providers about the importance of advance care planning.”

Advance Care Planning - What does it all mean? - SoundCloud
(1428 secs long, 336 plays)Play in SoundCloud
References:
  1. Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. J Patient Saf. 2017;13(2):51-61. https://www.ncbi.nlm.nih.gov/pubmed/28198722
  2. Mirarchi FL, Yealy DM. Lessons Learned From the TRIAD Research Opportunities to Improve Patient Safety in Emergency Care Near End of Life. J Patient Saf. April 2018:1. https://www.ncbi.nlm.nih.gov/pubmed/29621035
  3. Guidelines for Emergency Physicians on the Interpretation of Physician Orders for Life-Sustaining Therapy (POLST). Ann Emerg Med. 2017;70(1):122-125. https://www.ncbi.nlm.nih.gov/pubmed/28645409
  4. Richardson DK, Fromme E, Zive D, Fu R, Newgard CD. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann Emerg Med. 2014;63(4):375-383. https://www.ncbi.nlm.nih.gov/pubmed/24210466

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ED physicians and APPs see older patients in the ED for falls every. single. shift. On this episode, geriatric EM expert Shan Liu talks about preventing future falls from the ED, and the fact that we should retire the term “mechanical fall”. Unfortunately, this term is potentially misleading and can downplay the serious nature of the patient’s falls risk.

Falls are very common among older adults and come with a high risk of future falls and also of trauma-related morbidity and mortality. There is more we could be doing in the ED to prevent future falls.

Preventing Future Falls - SoundCloud
(1220 secs long, 206 plays)Play in SoundCloud
References:
  1. Geriatric ED Guidelines, from ACEP, AGS, ENA, and SAEM
  2. Nagaraj G, Hullick C, Arendts G, Burkett E, Hill KD, Carpenter CR. Avoiding anchoring bias by moving beyond ‘mechanical falls’ in geriatric emergency medicine. Emerg Med Australas. August 2018.
  3. Tirrell G, Sri-on J, Lipsitz LA, Camargo Jr CA, Kabrhel C, Liu SW. Evaluation of older adult patients with falls in the emergency department: discordance with national guidelines. Acad Emerg Med. 2015;22(4):461-467.
  4. Sri-On J, Tirrell GP, Kamsom A, Marill KA, Shankar KN, Liu SW. A High-yield Fall Risk and Adverse Events Screening Questions From the Stopping Elderly Accidents, Death, and Injuries (STEADI) Guideline for Older Emergency Department Fall Patients. Geson LW, ed. Acad Emerg Med. 2018;25(8):927-938.
  5. Liu SW, Obermeyer Z, Chang Y, Shankar KN. Frequency of ED revisits and death among older adults after a fall. Am J Emerg Med. 2015;33(8):1012-1018. doi:10.1016/j.ajem.2015.04.023.
  6. Shankar K, Liu S, Ganz D. Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003-2010. West J Emerg Med. 2017;18(5):785-793.
  7. Shankar KN, Taylor D, Rizzo CT, Liu SW. Exploring Older Adult ED Fall Patients’ Understanding of Their Fall: A Qualitative Study. Geriatr Orthop Surg Rehabil. 2017;8(4):231-237.

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

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Older adults often present to the ED for or with confusion or agitation. It is important to have a framework for assessing these patients, diagnosing the presence of delirium or dementia, looking for underlying causes, preventing worsening, treating the underlying condition, and sometimes treating the symptoms. The ADEPT tool is the newest one in a toolbox of resources being released by ACEP to provide quick access to basic clinical guides while on shift. This episode is introduced by former ACEP president, Sandy Schneider, and covers the details of the ADEPT tool.

The ADEPT tool is the product of a collaborative effort on the part of a group of physicians with expertise in EM, geriatrics, psychiatric medications, with input from other outside specialists.

Two important take-home points of ADEPT are:

  1. Always look for an underlying cause or causes in patients with delirium.
  2. In treating agitated patients, it is important to avoid causing harm. Many medications in doses that are used in younger agitated patients can cause prolonged sedation or even paradoxically worse agitation in older patients.

It can be accessed online at: www.acep.org/adept

ADEPT - SoundCloud
(1640 secs long, 604 plays)Play in SoundCloud

Disclosures:

Funding for the creation of the ADEPT tool was in part provided through a grant from the Allergan Foundation, and it was created with support from ACEP, the Coalition on Psychiatric emergencies, and the Emergency Medicine Foundation. Dr. Shenvi received funding through ACEP as part of the team creating the ADEPT tool.

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There is some confusion, disagreement, and misunderstanding surrounding orthostatic vitals in the ED. Older patients have a high rate of incidentally-found positive orthostatic vital signs, typically because of heart-rate changes. So emergency physicians may be reluctant to request orthostatics. However, in patients with syncope or falls, the presence of orthostatic hypotension and of symptoms may actually be helpful. It can help clarify the cause of syncope, potentially help avoid unnecessary testing or hospitalization, and can also help direct treatment and interventions to prevent future syncope or falls. In this episode, Maura Kennedy (@MauraKennedyMD) talks us through a recent paper she authored on orthostatic vitals in older adults in the ED.

The paper we discuss is available here: Kennedy et al. “Recondisering orthostatic vital signs in older emergency department patients” Emerg Med Australas. 2018, June 21. PMID 29931795

You can tweet thoughts or comments to @gempodcast or @MauraKennedyMD

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

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IV subdissociative dose ketamine (SDK) is used with increasing frequency for acute pain management in the ED. However, most studies have excluded older adults in assessing its efficacy and safety. In this episode, Sergey Motov (@painfreeED) discusses his recent paper “Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial” published in the American Journal of Emergency Medicine in May 2018.

This study enrolled patients age 65 and over and compared ketamine 0.3mg/kg over 15min vs morphine 0.1mg/kg over 15min for reduction of acute pain. Ketamine provided better improvement in pain at 15min, and similar pain improvement compared to morphine at 30min. However, there were significantly more side effects in the ketamine group, including dizziness, feeling of unreality, and hallucinations.

Future studies will focus on trying lower doses over longer infusion times to potentially reduce the side effects.

For more on pain management in the ED see Dr. Motov’s website: http://www.painfree-ed.com/

Reference:

Motov S, Mann S, Drapkin J, et al. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. May 2018.   https://www.ncbi.nlm.nih.gov/pubmed/29807629

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This podcast uses sounds by Jobro and HerbertBoland

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