“Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.” This statement was one of ACEPs 2013 Choosing Wisely recommendations. How palliative care can be effectively and practically integrated into the ED, and which patients are likely to benefit from it is still being worked out at many institutions.1–4 However, it is clear that the time for palliative care in the ED has come.
ACEP goes on to expand on their recommendation: “This is medical care that provides comfort and relief for patients who have chronic or incurable diseases. Early referral from the emergency department to hospice or palliative care services can benefit patients, resulting in both improved quality and quantity of life.”
What is Palliative Care?
First it is important to understand what palliative care is and isn’t. Palliative care is not equivalent to hospice care. Hospice care can only occur when a patient meets strict criteria that strongly predict death within 6 months. While we most often think about palliative care near the end of life, it is appropriate to offer it to patients as early as the time of diagnosis of a serious illness. Palliative care can occur concurrently with curative therapy, for symptom management, and can also continue once curative efforts have ceased and once a patient is on hospice. In some cases, palliative care can actually prolong life.
The WHO defines palliative care as “care which improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosoial support from diagnosis to the end-of-life and bereavement.” The WHO further delineates palliative care as the following:
- provides relief from pain and other distressing symptoms;
- affirms life and regards dying as a normal process;
- intends neither to hasten or postpone death;
- integrates the psychological and spiritual aspects of patient care;
- offers a support system to help patients live as actively as possible until death;
- offers a support system to help the family cope during the patients illness and in their own bereavement;
- uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
- will enhance quality of life, and may also positively influence the course of illness;
- is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
Palliative care involves managing both the symptoms of disease and the side effects of medications (such as chemotherapy), including nausea, pain, constipation, dry eyes, skin breakdown, anorexia, cognitive failure, dry mouth, and respiratory dysfunction or “air hunger”. Another component is helping patients and families understand treatments and prognoses, and make decisions regarding pursuing or declining interventions or medications. It can also mean helping coordinate care options such as hospitalization, outpatient therapy, home health nursing, or other non-hospital facilities.
“Patients can live better, less expensively, and longer with palliative care.” – Karen Jubanyik, MD, Yale University, an EM physician with an interest in improving palliative care in the ED
Who Provides Palliative Care?
The tenets of palliative care can be applied across all specialties, including emergency medicine, and physicians of many different specialties, including EM, can now pursue fellowship training in Hospice and Palliative Care Medicine.5 The certification exam was first available through the ABMS in 2008.
For those who have an interest in palliative care and wish to champion it in their own hospitals and EDs but who cannot take the time to pursue a full fellowship, there are many other opportunities for training courses or ‘bootcamps’, such as EPEC-EM and IPAL-EM. These programs are intended to help ‘train the trainer’ so that physicians can bring back ideas they have learned and incorporate them into their own ED or residency training program. ACEP also has a palliative medicine section that is creating a palliative care toolbox for clinicians.
How can Palliative Care be Provided in the ED?
In one sense, we all incorporate aspects of palliative care into our every day practice. However, we often lack the time to give detailed attention to patients’ symptoms or side effects, much less to help coordinate home health nursing or have lengthy discussions regarding goals of care. We may also lack the expertise to deal with complex symptoms and side effects. Sometimes we may lack information needed to have these discussions, such as an accurate prognosis for patients with cancer.
There are several different models for how palliative care can be more robustly integrated into the ED. These models are not mutually exclusive, and can exist and function simultaneously. This list is not exhaustive, as many hospitals continue to develop systems that work within their specific resources and limitations.
- EM physicians as providers of palliative care – This is the simplest model, in which EM physicians receive training in the concepts of palliative care and symptom management, and can help identify patients who may benefit from more aggressive symptom management and less aggressive curative treatment. The EM physician may involve a multi-disciplinary team to help with this, including social workers or case managers, or chaplains.
- ED consult teams – Some hospitals have geriatrics or palliative care teams that can consult with the patient in the ED. These teams can help with decision making regarding goals of care, and can make recommendations for pain or symptom management as well as potential alternatives to hospitalization. This model has the potential to reduce ICU and hospital admissions, thereby reducing costs of care.
- Inpatient consult teams – In many hospitals, particularly on nights and weekends, patients have to first be admitted to the hospital to receive an inpatient palliative care consult. Inpatient teams have been found to reduce costs of care.6,7
- Next day palliative care appointments – If a patient does not require inpatient admission, some hospitals have set up availability of next day appointments for patients to see a palliative care provider.
The recently released Geriatric Emergency Department Guidelines, which are recommendations for the ED care of older adults, include palliative care as an important component (See a prior ALiEM post on the guidelines). The Guidelines note that:
“By providing multidisciplinary teams for palliative care interventions, recent literature suggests this will improve quality of life, 8 reduce hospital length of stay 9 and ED recidivism, 10 improve patient and family satisfaction,4 result in less utilization of intensive care, and provide significant cost savings.” 6,7
Palliative Care Places an Emphasis on Patient Preferences
One of the major tenets of palliative care is helping patients and family members understand the disease process and options so that patients can make the best decisions based on their own goals, preferences, and beliefs. Tim Platts-Mills, MD, MSc, a University of North Carolina EM physician and geriatric emergency medicine researcher summarizes the importance of palliative care from the patient perspective in the following way:
“Bringing palliative care to the emergency department is an essential step in achieving the important goal recently defined in the Institute of Medicine report on Dying in America of ‘honoring individual preferences near the end of life’. For older adults with substantial disability from a chronic illness who present with a life-threatening condition, emergency physicians need to act quickly to ascertain the preferences of the patient and, when appropriate, protect the patient from a system which is designed to provide far more advanced medical care than some patients desire. The palliative care approach can greatly improve the patient experience of dying, and more physician education, improved access to information about patient preferences, and access to inpatient teams which can support and continue this approach in the hospital are needed.”
The New York Times 11 recently reported on the failures of the US healthcare system in meeting the needs of patients near the end of life, after the Institute of Medicine released its report on Dying in America. The author concluded with this quote from Dr. Victor Dzau, the president of the Institute of Medicine:
“Patients don’t die in the manner they prefer. The time is now for our nation to develop a modernized end-of-life care system.”
How Does YOUR ED Provide Palliative Care?
I would be interested to hear how your ED is providing palliative care. Leave a comment about how your system works, or with thoughts and ideas.
With gratitude to Karen Jubanyik for sharing her expertise and knowledge in the field of ED-based palliative care.