Page 181 - PJ MED OPS Handbook 8th Ed

11. Palliative Care

1. Identify critically ill patients by appearance, vital signs or both. Examples may include:
a. GCS 3 due to TBI (not non-TBI hemorrhage!)
b. Signs of impending herniation (Cushing’s triad)
c. Development of bradycardia in setting of hemorrhage despite resuscitation attempt
d. “Dismemberment” injuries (high amputations not amenable to TQ, significant torso tissue
loss, etc.)
e. Severe hypoxia despite secure airway and positive pressure ventilation (persistent sats
<80%)
f. CPR >15min in the setting of unwitnessed cardiac arrest
2. In some instances, it will be obvious that the patient is dying and beyond your ability to save
them.
3. In other instances, it will not be clear if the patient is dying. Therefore, it may be safer to con-
tinue active treatment. Sometimes time, tactics and logistics will influence this decision.
4. Use experience and judgment to determine if the ability to save a patient is beyond your expe-
rience, capability or scope of practice.
5. In either case, it is helpful and important to get telecon support, and usually with a medical
known and trusted provider. This will make the discussion and decision-making easier.
6. When deciding to institute palliative care, discontinue active treatments and continue comfort
care only.
7. Provide analgesia and keep patient pain free if able.
8. Use Zofran for nausea.
9. Treat fever with meds or wet compresses.
10. Keep patient clean and comfortable.
11. Touching the patient on a shoulder, arm or hand can be reassuring and comforting.
12. Talking in soothing tones may be helpful. Reassure patients you are well trained for this and
will take good care of them.
13. Use your judgment to tell a patient he/she is dying or not. Many times you do not need to
discuss this if not asked.
14. Stay with the patient as much as feasible. Even if they sleep and wake intermittently it can
alleviate fear of being alone.
15. Professionally manage other people involved in the situation (e.g., fellow crewmembers or
family). Ask questions about what they understand is going on. Tell them you are trained and
doing your best but that resources and time are limited. Explain that we generally intervene to
save a life but if that is not possible, the main thing is to reduce suffering. Develop a therapeu-
tic alliance with the crew/team/family so they feel they are part of the decision and trying to
help (can help with nursing, comforting, etc.). Avoid adversarial situations and try to build trust
up front before you announce a palliative care decision.
16. If you go through an experience like this, make sure to debrief with a mental health provider or
flight surgeon. Discuss it with your teammates.
17. The best preparation to reduce mental health concerns from these events is to be optimally
trained and know that you did everything you were capable of.

Chapter 11. Palliative Care n 179