New programs ensure emergency medicine residents learn hospice and palliative medicine skills.
• Currently, there is no nationally defined hospice and palliative medicine curriculum for emergency medicine resident training;
• ED providers may feel ethically conflicted about providing aggressive care;
• Residency programs vary in how much palliative medicine skills are taught, if at all.
ED providers see patients with serious, life-limiting illness every day. “Our training has traditionally been focused on resuscitation and fixing the problem. But the reality is that some patients are not there for a cure,” says Eric Isaacs, MD, clinical professor of emergency medicine at Zuckerberg San Francisco General Hospital.
In fact, many patients go to the ED to address pain, fear, symptom control, or just the need for communication. Good care, says Isaacs, “doesn’t always mean full speed ahead to the ICU. Sometimes, it means taking a little bit of time to ask questions and recognize that the situation might call for a different approach.”
However, emergency medicine (EM) residents have very little time to learn hospice and palliative medicine skills. This includes symptom management and effective communication. There currently is no nationally defined hospice and palliative medicine curriculum for EM resident training.
“For decades, people have assumed that the ED is a place you go to be resuscitated, and that the only thing we know how to do is put our foot on the accelerator, so to speak, and push for aggressive care,” says Isaacs.
ED providers feel ethically conflicted about providing aggressive care when it seems inappropriate. “If you talk to emergency physicians who’ve been doing this for 25, 30 years, they never thought it was the right thing to do. But they didn’t have the skill set to take care of these patients,” says Isaacs.
There is growing recognition that the ED providers play a key role in preventing unwanted care and hospitalizations. “If we can talk to the patients and their families, learn about their values and hopes, and give the right care at that time, we are making a huge difference,” says Isaacs.
An expert consensus group set out to develop hospice and palliative medicine milestones within a competency framework, relevant to the ED setting.1
“The group decided that one of our first projects would be to see if we could come up with a suggested framework for residency program directors to use in assessing and developing EM resident skills,” says Jan Shoenberger, MD, who served on a subcommittee on curriculum development.
The group identified relevant knowledge, skills, and behaviors. Their framework was modeled after the widely accepted Accreditation Council for Graduate Medical Education (ACGME) EM milestones.
“We knew that it was something that residency directors were comfortable and familiar with,” explains Shoenberger, vice chair of operations and clinical education in the department of emergency medicine at Los Angeles County and USC Medical Center.
All subcommittee members were emergency physicians who had an interest and training in hospice and palliative medicine. Many are board-certified in hospice and palliative medicine in addition to emergency medicine.
“Also, many of us have expertise in education,” says Shoenberger, a former EM residency program director. “Going forward, we knew that the ACGME will eventually publish and develop a new version of the milestones for emergency medicine.”
The group hopes their effort would stimulate some thought from the ACGME on adding a separate milestone for these skills or integrating some of the language into existing milestones.
“We would like it to be something that is assessed and measured during residency training in EM,” says Shoenberger.
For hospital ethicists, the work signals the desire of the EM community for improved expertise in dealing with end-of-life issues. “We believe that one good way to address this need is through asking our residency programs to integrate these skills into their curricula,” says Shoenberger.
Palliative care in emergency medicine is relatively new, notes Isaacs, chair of the American College of Emergency Physicians’ palliative medicine section. Not all training programs include palliative care “champions” to advocate for the inclusion of these skills. “In fact, there are probably about 150 board-certified emergency physicians who are also board-certified in palliative medicine. And many of them are in the same place,” says Isaacs.
Some programs have achieved buy-in from their residency administration to include these skills. In other programs, there is almost no training at all. “And if it is being done, it isn’t being done very well,” says Isaacs. Residents appreciate gaining the expertise. “What I’m seeing now is that residents are sharing some of the nuances and skills in this area even with their supervisors, who may not have been trained accordingly,” says Isaacs.
Historically, the discipline of emergency medicine managed acute problems. A growing number of people who are chronically, and perhaps terminally, ill are presenting to EDs. “More and more, we realize that we set the stage for what happens to the patient in the healthcare trajectory,” says Sangeeta Lamba, MD, associate dean of education at Rutgers New Jersey Medical School.
EM residents need expertise to manage this burgeoning patient population, as ED care plays a big role in the management of their last stages of life. “Our discipline has to grapple with whether we are giving the right tools not just for acute care, but also for patients who are chronically and perhaps even terminally ill — because the same rules do not apply,” says Lamba. ED providers need to evaluate if the patient values quality over quantity of life; for instance, a person with congestive heart failure may not wish to live out their last few days in the hospital.
Gathering pre-existing documentation on code status, healthcare proxies, or advance care planning becomes very important in the ED.
“It goes beyond the question of whether the patient should be on a ventilator or not,” says Lamba.
Even if the patient does end up going to the ICU, says Lamba, “the team is already aware, the family is already engaged, and there is less conflict later.”
1. Shoenberger J, Lamba S, Goett R, et al. Development of hospice and palliative medicine knowledge and skills for emergency medicine residents: Using the Accreditation Council for Graduate Medical Education milestone framework. AEM Educ Train 2018;2(2):130-145.
• Eric Isaacs, MD, Clinical Professor of Emergency Medicine, Zuckerberg San Francisco General Hospital. Email: email@example.com.
• Sangeeta Lamba, MD, Associate Dean of Education, Rutgers New Jersey Medical School, Newark. Email: firstname.lastname@example.org.
• Jan Shoenberger, MD, Vice Chair of Operations and Clinical Education, Department of Emergency Medicine, Los Angeles County and USC Medical Center/Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of USC. Email: email@example.com.