Discussion - tPA Stroke

We discussed risks, benefits and alternatives to tPA with the [patient/family] at this time.  We specifically discussed the results of the NINDS study which suggested that 8 out of 18 stroke patients who receive tPA according to a strict protocol will recover by 3 months after the event without significant disability.  We discussed that this is compared to 6 out of 18 stroke patients (one-third) who recover substantially regardless of treatment.

We discussed that tPA has potential risks, which include bleeding into the brain, other types of serious bleeding, and even death that vary by studies.  We discussed the following risks:

-The NINDS study suggested that bleeding into the brain occurred in about 1 out of 18 patients receiving tPA (specifically, 5.8%).  When this occurred, there was a 45% fatality rate.

-Several studies suggested treatment with “clot-dissolving” medications increases the number of patients who die following a stroke.

-Subsequent studies demonstrated that using tPA more liberally than is recommended in NINDS protocol resulted in a higher rate of intracranial hemorrhage.

We also discussed that tPA complications are more likely in patients over 70 years of age, those with more severe stroke (NIHSS over 15), or those with an elevated blood glucose (specifically >300 mg/dL).  After discussion of these risks, the [patient/family] wished to [be treated with tPA/refuse treatment with tPA].

https://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf

Discussion - PECARN

Discussed PECARN pediatric head trauma algorithm with the patient’s [mother/father/parents] to identify children with head injury at very low risk for clinically significant head injury.  Discussed that by applying this clinical decision rule, the patient has a risk of clinically important traumatic brain injury (ciTBI) of [<0.02/0.9/##]%.  Discussed risks and benefits of observation and CT studies with recommendation for [observation/CT of the head] at this time based on [very low/increased] risk of ciTBI.

Patient’s [mother/father/parents] demonstrated understanding of risks, benefits, and alternatives, and agreement with plan for [observation/CT] at this time.

https://www.mdcalc.com/pecarn-rule-low-risk-febrile-infants-29-60-days-old

Discussion - Goals of Care

I personally reviewed [Mr./Mrs. Name]'s history to include prior admissions, diagnostic testing, and previously discussed treatment options.  It was noted that the patient [does/does not] have an [advanced directive/DNR/DNI].  Given [his/her] history of [previously diagnosed life-limiting disease], I wanted to discuss their goals of care at this time.  [Mr./Mrs. Name]'s [all family members present preferably with names] were at the bedside and invited to be involved in this discussion with the patient's permission.  [Nurse or other specialists] were also at the bedside as part of this conversation.  We offered to have a Chaplain at the bedside [which patient accepted or refused/Chaplain's name].

[Mr./Mrs. Name] states their primary goal today is [relief of pain/etc.].  [Mr./Mrs. Name] states that they [would/would not] wish to have a breathing tube placed or be placed on a ventilator should their condition worsen to the point this might be necessary.  [Mr./Mrs. Name] states that they [would/would not] wish to be resuscitated with compressions on their chest, electric shocks (defibrillation), or have resuscitative ACLS drugs given should their heart stop beating or go into a non-perfusing rhythm.  [Mr./Mrs. Name] does wish to have [describe treatments patient agrees to here].

We allowed [Mr./Mrs. Name] and their family to have all of their questions answered to the best of our abilities.  We discussed plan for [admission/further treatment].

https://emottawablog.com/2019/04/a-how-to-guide-to-goals-of-care-discussions-in-the-emergency-department/
https://www.aliem.com/pv-card-palliative-care-screening/

Discussion - Leaving Against Medical Advice (AMA)

I was informed that the patient wishes to leave against medical advice (AMA) at this time.  I have discussed with the patient their desire to leave AMA, and they state their reason for wanting to leave is [in patient’s words].  The patient demonstrates a normal mental status and adequate capacity to make medical decisions.

I discussed alternatives to leaving at this time including [alternate treatment or evaluation], and patient still expressed a desire to leave AMA.  I discussed the risks of leaving AMA with the patient, including [risk], worsening illness, chronic pain, permanent disability and death.  The patient was given the opportunity to ask questions about their medical condition, which I answered to the best of my ability.  The patient was treated to the extent that they would allow, and was encouraged to return to the Emergency Department at any time should they change their mind or if their condition worsens.

The AMA discussion was witnessed by [nurse’s name].  The patient was encouraged to follow up with their primary care doctor as soon as possible for further evaluation.

https://www.the-hospitalist.org/hospitalist/article/124731/how-do-i-determine-if-my-patient-has-decision-making-capacity

Discussion - Chronic Pain

Reassessed patient at this time and discussed recurrent [site] pain issues with [him/her].  This is the [###] time the patient has been evaluated in this Emergency Department for [site] pain in the past [time frame].  I emphasized with the patient that my training is primarily in the treatment of acute pain complaints, that [his/her] exam is reassuring at this time, and that definitive care of chronic pain is not the role of the Emergency Department.

[He/She] also was noted to be demonstrating the following behaviors known to be associated with inappropriate use of pain medications and addiction:

    -inability to restrict medications or take them on an agreed upon schedule

    -taking multiple medications together

    -doctor shopping

    -the use of non-prescribed psychoactive medications in addition to prescribed medications

    -noncompliance with recommended non-opioid medications or evaluations

    -a preoccupation with opioid medications

    -insistence on rapid-onset formulations and routes of administrations

    -reports of allergy or no relief whatsoever from non-opioid treatments

I explained to the patient that I felt that providing opioid medications from the Emergency Department was counterproductive in that this may cause or exacerbate tolerance, acute overdose, physiological or psychological dependence, or withdrawal.  We discussed that opioid use in the management of chronic pain is best managed by a single practitioner, such as a primary care provider or pain specialist.  We discussed adjunctive therapies such as heat, ice, and exercise, as well as non-opioid medications such as Acetaminophen, NSAIDs, antidepressants, lidocaine patches, Gabapentin, and Pregabalin.  We discussed that additional medications for pain management should be discussed with a primary care provider, as some require close monitoring.

I reiterated to [Patient’s Name] that the most effective management of [his/her] chronic pain is a multimodal approach coordinated by [his/her] primary care provider, that may include physical therapy, cognitive behavioral therapy, and referrals to specialists in pain management.

https://www.acep.org/patient-care/smart-phrases/why-narcoticopioid-medications-were-not-prescribed/
https://www.acep.org/patient-care/smart-phrases/emergency-naloxone-programs---information-for-providers/
https://www.acep.org/patient-care/smart-phrases/emergency-naloxone-programs---patient-information/