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PV Card: Palliative Care Screening in the Emergency Department

Palliative Care canstockphoto3674078What is Palliative Care? It is specialized medical care focusing on improving the care and quality of life for patients with advanced illness by decreasing suffering. It can be delivered concurrently with curative care. Early identification of patients who are likely to benefit is key. How do you decide whether your patient could benefit from a palliative care consult?

Hot off the presses

We just published in Academic Emergency Medicine a validated screening tool to identify ED patients who would benefit from palliative care [PubMed abstract].1 In an effort to accelerate knowledge dissemination, the checklist is reproduced here in PV card form. Be sure to check out the thoughtful expert peer review below by Dr. Kate Aberger, who is the chair of the ACEP Palliative Care Section.

PV Card: Palliative Care Screening Tool

Adapted from 1–3
Go to the ALiEM Cards site for more resources.

(c) Can Stock Photo

George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J. Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs. Acad Emerg Med. 2015;22(7):823-837. [PubMed]
Grudzen C, Richardson L, Morrison M, Cho E, Morrison R. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17(11):1253-1257. [PubMed]
Wu F, Newman J, Lasher A, Brody A. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med. 2013;16(11):1362-1367. [PubMed]

Expert Peer Review by Dr. Kate Aberger

As physicians we have a duty to patients and their families to relieve suffering. As emergency physicians, we are in a unique location and position to provide needed palliative care services, or at the very least make the recommendation or referral.

As outlined in this wonderful pocket card, there are large populations of patients who have unmet palliative care needs. These patients are shuffled between specialists as well as between the hospital and the subacute rehab or other care facilities. We in the ED touch them at every transition! We are the HUB of care!

When we see patients who meet the criteria listed on this card – someone with a serious illness plus multiple admissions or functional decline or uncontrolled symptoms, we need to think about palliative care. As we make our assessments, we think about trajectory of illness – where do they fall? Initial stages? End stages? Then we must think about prognosis – this is difficult, and if time is short, the only question you need to ask yourself is “would you be surprised if this patient died on this admission? In the next 6 months? 12 months?” If the answer is yes – call a consult.

When we aggressively address active symptoms in the ED, we not only relieve suffering, we engender the trust of the patient and the family – we show them that their well-being is important and urgent. When the patient “feels better”, the family relaxes, and the real conversations can begin. Ask the patient and family what they understand about their illness. Fill in the gaps of knowledge. Offer prognostic information. Ask what is most important to them if their time is short. Help them achieve those goals.

As a follow up, the next pocket card may be entitled “symptomatic treatment for the palliative patient” with more specific drugs and dosages. As outlined there are only a few needed – Haldol is an excellent agent to use for intractable nausea and vomiting, as well as for delirium/agitation. Use Morphine for pain and especially for shortness of breath at appropriate doses – not forgetting to take into account whether or not the patient is opiate-naïve or not. Using non-pharmacological interventions to relieve shortness of breath – a fan, open curtain or window. Atropine optho drops placed sublingually can dry up terminal secretions (“death rattle”). Don’t forget to ask about constipation!

Palliative care is essential in the care of patients with complex serious illness – regardless of where they are in their trajectory of illness. It is a means to aggressively relieve suffering, help patients navigate the healthcare system keeping their goals at the forefront of every decision.

Dr. Amy Gelfand
Chair, ACEP Palliative Medicine Section; Department of Emergency Medicine Faculty, Dept. of Internal Medicine, Division of Palliative Medicine, St Joseph’s Healthcare System, Paterson; NJ Instructor of Clinical Emergency Medicine
Naomi George, MD

Naomi George, MD

Emergency Medicine resident
Department of Emergency Medicine
Brown University
Naomi George, MD

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Kalie Dove-Maguire, MD

Kalie Dove-Maguire, MD

Emergency Medicine resident
Department of Emergency Medicine
University of California, San Francisco-SFGH
Kalie Dove-Maguire, MD

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