Original ContributionsInitiating Palliative Care in the Emergency Department
Introduction
In 2006, nearly a quarter of a million patients arrived dead or died in the Emergency Department (ED) (1). Managing the actively dying and providing relief from suffering falls directly under the purview of Emergency Medicine. Quest et al. identified 12 palliative care skills that Emergency Physicians (EPs) should learn to manage patients effectively in the ED: assess illness trajectory, formulate prognosis, communicate bad news, plan advanced care, resuscitate the terminally ill with family members present, manage pain and non-pain symptoms, withdrawal and withholding of care, manage the imminently dying, manage hospice patients and palliative care systems referrals, understand ethical and legal issues pertinent to end-of-life care, display spiritual and cultural competency, and manage the dying child (2). Despite this, further education in end-of-life care and its role in the ED are clearly needed (3). Currently, fewer than 18% of residents and medical students receive formal end-of-life care education, and there is a paucity of end-of-life care information in medical textbooks 4, 5.
We use a case presentation to illustrate how palliative care (PC) can frequently be incorporated into ED care, but is often overlooked. The case is representative of patients seen in EDs every day across the country and is used as a framework to discuss key issues in PC in the ED.
Section snippets
Definitions
The American Academy of Hospice and Palliative Medicine defines the goal of PC as “to prevent and relieve suffering and to support the best possible quality of life for patients facing life-threatening or debilitating illness and their families, regardless of the stage of the disease or the need for other therapies” (6). The World Health Organization defines PC as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening
Incorporating Palliative Care into the ED: An Illustrative Case
A 62-year-old Hispanic woman presented to the ED in respiratory distress. The patient did not speak English, but her caregivers, her two oldest daughters, were at the bedside to translate. Upon entering the room, the oldest daughter said that her mother, “has lung cancer and she was just discharged from the hospital yesterday.” She stated that after her mother’s chemotherapy treatment that morning she did not feel well and the Internal Medicine service evaluated her in the Cancer Center and
Conclusion
As the American population continues to age and there are increasingly older Americans with chronic and terminal illnesses, EPs will be at the forefront of emergent symptom management for the near dead and the actively dying. EPs should learn effective management strategies and how to appropriately refer patients to PC.
The under-utilization of PC services throughout the health care system has drastic implications for patients, their families and caregivers, and the system as a whole. PC
References (37)
- et al.
Hospice and palliative medicine: new subspecialty, new opportunities
Ann Emerg Med
(2009) - et al.
Hospice enrollment and pain assessment and management in nursing homes
J Pain Symptom Manage
(2003) - et al.
Treating cancer patients who are near the end of life in the emergency department
Emerg Med Clin North Am
(2009) - et al.
The health impact of health care on families: a matched cohort study of hospice use by decedents and mortality outcomes in surviving, widowed spouses
Soc Sci Med
(2003) - et al.
A randomized controlled trial of hospice care
Lancet
(1984) - et al.
What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program?
Soc Sci Med
(2007) - et al.
National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary
Natl Health Stat Report
(2008) A case for education in palliative and end-of-life care in Emergency Medicine
Acad Emerg Med
(2009)- et al.
The status of medical education in end-of-life care: a national report
J Gen Intern Med
(2003) - et al.
End-of-life care content in 50 textbooks from multiple specialties
JAMA
(2000)
In search of a good death: observations of patients, families and providers
Ann Intern Med
Factors considered important at the end of life by patients, family, physicians, and other care providers
JAMA
Death foretold: prophecy and prognosis in medical care
Cited by (30)
Emergency department staff perceptions of their roles in providing end of life care
2023, Australasian Emergency CareCitation Excerpt :In contrast, the education of emergency doctors and nurses aims to equip them with the knowledge and skills to prevent deaths and provide lifesaving interventions, for example resuscitative interventions, treatment modalities, and technology to prolong life [5,6]. Despite this misalignment between responsibilities and education, EOLC is increasingly becoming a part of emergency work and staff will need to have the skills required to provide care in a setting that is not aligned with the aims of EOLC [3,6]. The guiding principle for any quality EOLC requires a collaborative practice approach [7,8].
Factors affecting initiation of palliative care in a Ugandan Emergency Department
2021, African Journal of Emergency MedicineCitation Excerpt :Particularly relevant to low-resource settings, by prioritizing end of life wishes for those with incurable disease, limited resources may be directed towards those with reversible illness. The Emergency Department is an ideal location for initiation of palliative care, and this recognition is leading to ED-based palliative care interventions in high-income settings [10–12]. There is an even greater need for ED-based PC in low-income settings however it is not yet a routine component of Emergency Medicine training or practice on the continent of Africa.
United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department
2021, Annals of Emergency MedicineCitation Excerpt :ED-initiated palliative care consults have been shown to improve quality of life, reduce readmissions, and lower costs and inpatient length of stay while having no effect on survival.30-32,57 A collaborative relationship with a palliative care team can improve understanding of available resources and allow palliative care team members with specific expertise to address individual patient needs.54,64,98-101 For example, a palliative care-trained pharmacist may assist with pain control; case managers and social workers may assist with home health or hospice.
Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians
2020, Journal of Emergency MedicineThe Surprise Question Can Be Used to Identify Heart Failure Patients in the Emergency Department Who Would Benefit From Palliative Care
2019, Journal of Pain and Symptom Management