elder hand palliative emergency medicine care

The skilled and rapid resuscitation of critically ill patients is a central premise in the specialty of emergency medicine (EM). A paradox for providers often arises when in the midst of resuscitating a patient with advanced chronic illness, the question of risks versus benefits arises. For this patient, we may successfully stabilize vital signs, but at what cost? Will this patient return to a quality of life they deem acceptable? What are the patient’s goals of treatments given his/her underlying disease? These questions illustrate the need for emergency physicians to be more aware of and comfortable with palliative care practices.

What is Palliative Emergency Medicine? 

Palliative care is defined by the World Health Organization as:

“… an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual.”

As a “front-door” medical specialty for a variety of conditions and injuries across age groups, the emergency department (ED) can also serve as the front door to palliative care. We witness first-hand the acute presentations of infection, respiratory distress, neurologic compromise, and hemodynamic instability secondary to these illnesses. These acute changes in the disease course can serve as an opportunity to revisit goals and next steps in an effort to ensure that the care initiated by emergency providers is concordant with the patient’s own goals. These conversations have the potential to change the trajectory of the patient’s course of care.​1–3​ 

However, we emergency physicians are often not trained for this.​4​ There has been a lack of education on palliative care topics in the EM residency curriculum as the focus of EM has traditionally been to prolong life. As a result, we have developed a culture in which “success” is equated to “avoiding death.” We are rarely asked to consider when we are prolonging the dying process, and not the living.​5​ 

Palliative emergency medicine, defined as the integration of palliative care principles into emergency medicine practice, places the patient back at the center of care, eliciting the person’s own values, concerns, and decisions. It enables the physician to support those goals through clear communication, easing suffering, and creating a partnership. While not meant to replace the central premises of EM, incorporating palliative care skills into one’s armamentarium is meant to supplement and assist providers in providing care that is truly aligned with the patient and family. It is this shared partnership that may also be the key to physician resilience and longevity.​6​

Benefits for our emergency department patients

Palliative care is a truly patient-centered approach to care. There is no one definition of good quality of life. This is a dynamic process that is negotiated and re-negotiated amongst patients, families, and health care professionals, framed by individual values, knowledge, and preferences for care.​7​

What are the benefits of palliative care?​1​

  • Improved satisfaction for patients and families
  • Improved symptom management
  • Less time in the intensive care unit
  • Increased appropriate use of hospice
  • Better resource management

Initiating a palliative care consultation directly from the ED (versus later as an inpatient) shortens length of stay by an average of 4 days, resulting in fewer in-hospital deaths while significantly increasing quality of life, without reducing overall survival.​8​

A 2010 landmark study also reveals what many may consider surprising. Early palliative care intervention in patients with metastatic cancer increased length of survival by 3 months in a group with early palliative intervention and standard oncologic care, as compared to standard oncologic treatment alone, despite the fact that fewer patients in the early palliative care group received aggressive end-of-life care.​9​

Benefits for us as EM providers: Protective effects against burnout

Burnout rates for emergency providers can be as high as 65%, which is more than any other specialty and is seemingly increasing [ACEP News, 2017]. Our setting is ripe for emotional exhaustion and depersonalization given the nature of high acuity and overwhelming volume of patients needing care. 

Palliative care encompasses many of ideals, which have been noted to protect against compassion fatigue and burnout. 

  • Emotional resilience: Resiliency of the human spirit and the opposite of emotional exhaustion​10​
  • Compassion satisfaction: The pleasure derived from the work of helping others [The Concise ProQOL Manual PDF]
  • Exquisite empathy: “Highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement”​11​

The burnout phenomenon may be viewed as a result of a movement away from bedside care toward a more facile business-like knowledge of systems which enable “efficiency” within these systems. We may have moved from an experience of connections with patients to one of external facility. In this process, we have moved away from the deep satisfaction of what is non-physical about caring for patients. Building awareness of the emotional and spiritual needs of patients has a positive effect on both those providing the care and those receiving it.​11​

Palliative care offers the possibility to re-engage with patients about what is most important to them, placing the patient again at the center of care. What many of us seek in becoming physicians is a reciprocal healing process, which occurs through meaningful relationships, inner self-reflection, and a connection with peers and community.​10​ Palliative care offers this engagement, and hence offers us an ability to find our own emotional resilience. 

With a bird’s-eye view of the ED, it may not seem the ideal place for intimate questions about life and death. However, the ED bedside may be the richest place to do so, engaging the patient and family soon after s/he enters the hospital, in a vulnerable moment during an acute presentation, before his/her trajectory is set in motion. Here we may also find the keys to our own personal re-engagement as providers, with physicians and patients working together in a shared process, communicating about values and short- and long-term goals.

Call to action: Incorporate palliative care into EM practices

As emergency physicians, we can be the catalyst in a patient’s journey to begin crucial palliative care conversations with patients and their families. Consider tackling questions such as, “What is the meaning of living well for you?” In these conversations, we may uncover our own well-spring of emotional resilience. For many reasons, this conversation is perhaps one of our most relevant critical procedures in the ED.​8​

 Additional reading on ALiEM

References

  1. 1.
    Meier D, Beresford L. Fast response is key to partnering with the emergency department. J Palliat Med. 2007;10(3):641-645. https://www.ncbi.nlm.nih.gov/pubmed/17592971.
  2. 2.
    Mierendorf S, Gidvani V. Palliative care in the emergency department. Perm J. 2014;18(2):77-85. https://www.ncbi.nlm.nih.gov/pubmed/24694318.
  3. 3.
    Grudzen C, Stone S, Morrison R. The palliative care model for emergency department patients with advanced illness. J Palliat Med. 2011;14(8):945-950. https://www.ncbi.nlm.nih.gov/pubmed/21767164.
  4. 4.
    Quest T, Asplin B, Cairns C, Hwang U, Pines J. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med. 2011;18(6):e70-6. https://www.ncbi.nlm.nih.gov/pubmed/21676052.
  5. 5.
    Beemath A, Zalenski R. Palliative emergency medicine: resuscitating comfort care? Ann Emerg Med. 2009;54(1):103-105. https://www.ncbi.nlm.nih.gov/pubmed/19346031.
  6. 6.
    Schwenk T. Physician Well-being and the Regenerative Power of Caring. JAMA. 2018;319(15):1543-1544. https://www.ncbi.nlm.nih.gov/pubmed/29596590.
  7. 7.
    Steinhauser K, Christakis N, Clipp E, McNeilly M, McIntyre L, Tulsky J. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. https://www.ncbi.nlm.nih.gov/pubmed/11074777.
  8. 8.
    Wang D. Beyond Code Status: Palliative Care Begins in the Emergency Department. Ann Emerg Med. 2017;69(4):437-443. https://www.ncbi.nlm.nih.gov/pubmed/28131488.
  9. 9.
    Temel J, Greer J, El-Jawahri A, et al. Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. J Clin Oncol. 2017;35(8):834-841. https://www.ncbi.nlm.nih.gov/pubmed/28029308.
  10. 10.
    Kearney M, Weininger R, Vachon M, Harrison R, Mount B. Self-care of physicians caring for patients at the end of life: “Being connected… a key to my survival”. JAMA. 2009;301(11):1155-1164, E1. https://www.ncbi.nlm.nih.gov/pubmed/19293416.
  11. 11.
    Harrison R, Westwood M. Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy (Chic). 2009;46(2):203-219. https://www.ncbi.nlm.nih.gov/pubmed/22122619.
Beth Krafchik, MD

Beth Krafchik, MD

PGY-4 Resident Physician
Department of Emergency Medicine
Kings County Hospital Center/SUNY Downstate Medical Center
Beth Krafchik, MD

@BKrafchik

PGY-1 Emergency Medicine. Kings County, New York. Here for the FOAMed.
Beth Krafchik, MD

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Audrey Tan, DO

Audrey Tan, DO

Clinical Associate Professor
Department of Emergency Medicine
Division of Palliative Care, Department of Internal Medicine
NYU Langone Health
Audrey Tan, DO

@dratan_pallem

EM + Pall doc in NYC. Tweets are mine.
Audrey Tan, DO

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