Executive Summary

The emergency department setting presents many unique challenges for the provision of palliative care, including unanticipated severe illness and limited background information on patients. Experts suggest the following solutions:

• Emphasizing palliative care skills in residency training.

• Correcting providers’ misconceptions about legal requirements.

• Involving bioethicists in developing policies.

 

It is very easy for emergency department (ED) providers to “err on the side of caution” when deciding whether to institute life-sustaining therapies. “But this, in fact, may not be the best course of care,” says Tammie E. Quest, MD, director of Emory Palliative Care Center and associate professor in the Department of Emergency Medicine at Emory University School of Medicine in Atlanta.

ED providers are challenged with managing pain and other symptoms faced by patients with serious illnesses, and helping them decide about the use of invasive medical interventions.

“Emotions are high, and severe illness is often sudden and unanticipated,” says Ashley Shreves, MD, assistant professor in the Department of Emergency Medicine and the Brookdale Department of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York City. Here are other unique challenges involving palliative care in the ED setting, says Shreves:

• Limited background information is available to help physicians, patients, and caregivers make the decisions about the best path forward.

• Time and space are limited. “Discussions about the risks and benefits of proceeding with treatment that focuses on prolonging life, versus comfort and quality of life, take time,” says Shreves. “This is best done in a quiet space — a scarce resource in the ED.”

• ED providers have no established relationship with patients and families coming to them at their most vulnerable time. “Creating a therapeutic bond and gaining the trust of such patients and families can be challenging in the limited time available in the ED encounter,” adds Shreves.

• EDs are often loud, chaotic, and uncomfortable, with limited privacy. “This can be a particularly stressful environment for patients with advanced illnesses, and even worse for those at the end of life,” says Shreves.

In 2013, the American College of Emergency Physicians recommended, as part of the Choosing Wisely campaign, that emergency physicians not delay hospice and palliative care services for patients who might benefit from these in the ED setting.

“With this recommendation as a best practice in the field, we need the education and implementation tools necessary to deliver on this recommendation,” says Quest.

The Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-EM) and the Center to Advance Palliative Care’s Improving Palliative Care in Emergency Medicine (IPAL-EM) projects provide education and tools to improve the provision of palliative care in the ED. Quest is director of both projects.

“Increasingly, the evidence is building in the field to identify the most effective strategies,” says Quest. Still, a standardized approach is lacking.

In a 2014 study, 11 program leaders were interviewed on ED and palliative care integration. Researchers found that few collect outcomes-based metrics.1 When tracking does occur, there is a lack of standardization as to what metrics are used.

The IPAL-EM project, with expert consensus, provides guidelines on metrics that EDs can use to track outcomes. “While these have not yet become standard in the field, we have begun to see many programs throughout the country report metrics that may not yet have made it to the literature,” says Quest.

Both the culture of emergency medicine and financial reimbursement models push physicians to prioritize the use of invasive, life-sustaining treatments for their patients, says Shreves. This occurs regardless of the underlying illness and/or prognosis.

“Physicians should be rewarded for having the lengthy, challenging conversations that patients and families so desperately need and want, rather than discouraged from doing so as a result of time and financial pressures,” she adds.

Shreves recommends the following changes:

• Emphasizing palliative care skills in residency training.

“This would give physicians the basic knowledge to meet the symptom and psychosocial needs of patients with advanced illnesses,” says Shreves.

• Correcting providers’ misconceptions about legal requirements.

Fear about taking a misstep on this high-stakes terrain can dissuade physicians from even talking to patients and families about important end-of-life issues. “There is a considerable mythology concerning the ethical and legal boundaries that govern end-of-life decision-making,” explains Shreves.

• Involving bioethicists in developing policies for palliative care in the ED setting.

“Bioethicists could help create institutional policies and educational interventions that empower physicians to engage in the process more,” says Shreves.

 

Reference

  1. Quest T, Herr S, Lamba S, et al. Demonstrations of clinical initiatives to improve palliative care in the emergency department: A report from the IPAL-EM initiative. Ann Emerg Med 2013; 61(6):661-667.

SOURCE

• Ashley Shreves, MD, Assistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City. Email: ashley.shreves@mssm.edu.

• Tammie E. Quest, MD, Director, Emory Palliative Care Center/Associate Professor, Department of Emergency Medicine, Emory University School of Medicine, Atlanta. Email: tquest@emory.edu.