Rapid Clinical Updates: End-of-Life Care in the Hospital-Slides

Slides
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This Rapid Clinical Update focused on End-of-Life (EOL) care in the hospital setting, featuring experts Drs. Elizabeth Gundersen and Kencee Graves, moderated by Dr. Jagriti Chadha. The session emphasized recognizing appropriate patients and timing for serious illness discussions, managing symptoms at EOL, and communicating prognosis and care goals thoughtfully.

Key points included:

1. <strong>Early Identification and Conversations:</strong> Hospitalists should identify patients with serious illness early through tools like the "surprise question," monitoring functional status (a critical prognostic indicator, especially in cancer), and recognizing triggers like frequent readmissions or declining function. Early serious illness conversations help align care with patient values.

2. <strong>Communication Strategies:</strong> Words matter. Phrases like “there’s nothing else we can do” should be avoided; instead, focus on shifting goals toward symptom relief and quality of life. Making direct recommendations and avoiding “need” language helps families process decisions. Hope can coexist with realistic prognostic understanding.

3. <strong>Prognosis in Specific Conditions:</strong> Studies in older adults with chronic kidney disease show varied survival expectations and patient interest in prognosis, highlighting individualized discussions. Functional status and symptom burden guide prognosis estimation.

4. <strong>Symptom Recognition and Management:</strong> Common EOL symptoms include dyspnea, pain, secretions, and confusion. Signs predictive of death within days include apnea, Cheyne-Stokes breathing, decreased consciousness, and peripheral cyanosis. Opioid use should be carefully titrated; continuous infusions are appropriate only after stable high-dose use, avoiding premature initiation.

5. <strong>Delirium and Nausea/Vomiting Treatment:</strong> Haloperidol may be safe for ICU delirium symptom management but lacks definitive benefits on mortality. Low-dose olanzapine (2.5–5 mg at bedtime) can reduce non-chemotherapy-related nausea and the need for other antiemetics, mindful of QTc prolongation and dopamine antagonist co-use.

6. <strong>Deprescribing Guidance:</strong> International expert consensus supports deprescribing certain medications (e.g., ACE inhibitors, beta-blockers, statins, diuretics) in the last 3 to 6 months of life when benefits diminish.

The update reinforced hospitalists' unique role in identifying dying patients, initiating serious illness conversations, managing symptoms effectively, and supporting patient-centered, dignified EOL care.
Keywords
End-of-Life Care
Hospitalists
Serious Illness Conversations
Symptom Management
Prognosis Communication
Delirium Treatment
Nausea and Vomiting Management
Deprescribing
Functional Status
Chronic Kidney Disease