While screening and referral for palliative care is feasible in the emergency department setting, success usually hinges on availability of specialized personnel, according to a recent study. Some approaches to ensure ethical end-of-life ED care include the following:
- Create a relatively quiet space for dying patients.
- Ensure every clinician is trained in a comfort-based approach to end-of-life care.
- Take time to discuss the ethics of specific challenging end-of-life cases.
Multiple studies demonstrate that screening and referral for palliative care consultation is feasible in the emergency department (ED) setting, according to a recent analysis.1
“Over the last few years, there has been a real explosion of interest in the topic,” says Sangeeta Lamba, MD, associate professor of emergency medicine and director of ED palliative care at Rutgers New Jersey Medical School in Newark.
To date, 114 diplomates of the American Board of Emergency Medicine have obtained certification in the subspecialty of Hospice and Palliative Medicine since it was first offered in 2008. “The specialty itself — I call it emergency palliative care — has really grown,” says Lamba.
ED clinicians face competing patient priorities and time constraints, unlike the controlled environment of intensive care units, where the clinical team has some time to develop relationships with the patient and family. “In the ED, you have to do all the same care, but without the luxury of time and of having known the family,” says Lamba.
The ED team may experience moral distress if there is conflict in end-of-life decision-making. Physicians sometimes feel unable to adequately address not only the dying patient’s physical complaints, but also the person’s social and spiritual needs. “The passion for end-of-life care is there. It is part of the routine day-to-day work that we do,” says Lamba. She often hears frustration from residents, however, who want to do more, but lack the time necessary to fully focus on the needs of one family.
Creating a private space for grieving families is another challenge in a busy, crowded ED setting. “When a person comes in, our goal is to make a person live and the ED is geared to do so,” says Lamba. “When it is obvious that a person is not going to live, we may not be able to provide the environment to fully support the family.”
Reserving a separate room or space for dying patients, just as there is a separate area for geriatric or trauma patients, is one approach that some EDs have implemented. “Otherwise, the dying patient is smack in the middle of the room full of noise, and the family cannot grieve peacefully,” says Lamba.
In 2009, the Center to Advance Palliative Care created the Improving Palliative Care in Emergency Medicine initiative. (For more information on how to access CAPC tools, go to http://bit.ly/231wFWg.)
“The team created an online repository of tools and resources for ED clinicians,” says Lamba. “That really got emergency palliative care out in the world.”
One of the biggest barriers to good end-of-life care in the ED is knowing patient preferences when the patient cannot communicate, says Terri Schmidt, MD, MS, a professor in the Department of Emergency Medicine and a palliative medicine physician in the Department of Hematology/Oncology at Oregon Health & Science University in Portland.
Some patients do have an advance directive, but it is not available when the patient arrives in the ED. Often, advance directives are too vague for ED staff to act on. “Most say something like, ‘If I had a terminal illness, I would not want treatment that would only prolong the dying process,’” says Schmidt. “In the ED, we usually do not know if the conditions apply.”
Physician Orders for Life-Sustaining Treatment (POLST) forms turn patient preferences into medical orders that are based on the patient’s current medical condition and preferences. “However, POLST forms are often not immediately available to EMS [emergency medical services],” says Schmidt.
Some states are developing electronic registries for POLST forms to increase access. The Oregon legislature funded an electronic registry in 2009. “This requires professionals who sign a POLST form to submit it to the registry unless the patient opts out,” says Schmidt.
EPs CANNOT RELY ON OTHERS
As for whether patients can be screened in the ED for palliative care referral, Schmidt says, “I think the answer is ‘Yes, maybe.’ EDs are less likely to use a consult service that is only available certain hours.”
Currently, there is a shortage of outpatient palliative care services. “Screening would be valuable only if services are available,” says Schmidt.
Each of four studies reviewed by the researchers reported increased rates of palliative referral. Additional personnel were needed, though, to perform screening and referral. Success was limited by availability of specialized personnel, since palliative care teams aren’t available during off hours.
“In the middle of the night, it’s you who has to take care of not only the dying patient, but their loved ones and all the other patients in the ED,” says Lamba. Even if a formal palliative care consult team is unavailable, Lamba adds, there is value to screening since social workers or others can assist.
Since emergency physicians (EPs) cannot rely on the fact that palliative care specialists or others will be available, however, they need to master the necessary skills themselves. Thus, says Lamba, “education is a big, big component of taking it to the next step. The focus is on how to train every single emergency physician with the basic skills they need to care for the dying patient.”
While communication is one of the cornerstones of emergency medicine residency training, end-of-life communication poses some unique challenges. “Added to the fact that no one likes to deliver bad news, there is also an increased focus on survivors in addition to the patient,” says Lamba.
ETHICISTS CAN HELP
Schmidt doesn’t see ethics consults as a viable option to help clinicians manage end-of-life care in the ED. “Consults are not available 24/7 and they do not occur in a timely fashion,” she explains. “However, ethicists can help teach emergency professionals decision-making models.”
This can help ED professionals to feel more supported in making ethical decisions involving end-of-life care. “Ethicists probably can’t help us real-time in the clinical setting,” Lamba says. “But they can support us with ethical dilemmas that really weigh on our minds and our souls over time.”
Lamba suggests ethicists hold discussions on particularly difficult cases, such as when the emergency physician knows intubation will be futile but the family disagrees and wants aggressive care. Similarly, the EP can alert bioethicists if an ethically challenging case is admitted from the ED.
“We can give them a heads-up if we think that it can become a big ethical issue while the person is in-house,” says Lamba. “Quality care can start earlier rather than later.”
- George N, Phillips E, Zaurova M, et al. Palliative care screening and assessment in the emergency department: A systematic review. J Pain Symptom Manage 2016; 51(1):108-119.
- Sangeeta Lamba, MD, Associate Professor of Emergency Medicine and Surgery, Rutgers New Jersey Medical School, Newark. Phone: (973) 972-4823. Email: firstname.lastname@example.org.
- Terri Schmidt, MD, MS, Professor, Departments of Emergency Medicine and Hematology/Oncology, Oregon Health & Science University, Portland. Phone: (503) 494-7003. Email: email@example.com.