Palliative Care Integrated into Critical Care Settings, Including EDs
There is growing momentum toward incorporating palliative care services into the ED. Virtually all ED clinicians reported an overall positive perception to embedded palliative care, according to one analysis.1
Of 101 ED clinicians surveyed, 98% believed including palliative care in the ED was valuable or very valuable. “The ED is not the optimal place to have discussions about advance care planning or end-of-life care. But, often, patients and families are forced to confront these issues when emergencies strike,” says Elizabeth Clayborne, MD, MA, an adjunct assistant professor at University of Maryland School of Medicine.
At times, physicians are not well-equipped to provide quality palliative care in the ED. “This results in poor patient outcomes that do not address palliative care needs,” Clayborne laments.
Although palliative care is integral to providing quality care, in the ED the focus tends to be on aggressive and life-saving measures. “This puts patients whose goals of care do not align with these treatments in a vulnerable and often mismanaged state,” Clayborne observes.
More education and training is needed to make ED providers more comfortable with integrating palliative care there. This could include adding triage triggers to alert physicians when a patient would benefit from palliative services, such as advance care planning or improved pain management.
EDs are “both appropriate and effective places to provide palliative care,” says Chadd K. Kraus, DO, DrPH, FACEP, system director of emergency medicine research at Geisinger in Danville, PA.
In addition to symptom management and acute clinical care, the ED provides referrals to palliative care, initiates palliative care, admits patients to hospice, and consults with palliative care specialists. However, there are some challenges.
Emergency physicians often believe they lack time to involve palliative care. Even when they do try, palliative care specialists are not always available. “The availability of palliative care in the ED can be dependent on the location of the ED — rural vs. urban — and on local and institutional resources,” Kraus explains.
In many settings, palliative care specialists are not readily available to assist with patients in the ED. In contrast, at university hospitals or large academic medical centers, EDs frequently employ physicians with additional, specialized training in palliative care. “These physicians can champion and lead the clinical care of patients with palliative needs,” Kraus offers.
Implementing effective ways to equip emergency physicians in a range of ED settings with a foundational skill set in palliative care has become an active area of education in emergency medicine. “[Many] patients with conditions that benefit from palliative care present to the ED for acute, unscheduled care,” Kraus says. Palliative care for these patients is best delivered when and where they need it. Frequently, that is in an ED — and it happens during off-hours (nights, weekends, and holidays) when outpatient clinics or other sites of care are unavailable.
“Optimizing the patient-centered, interdisciplinary team approach with emergency physicians who have primary palliative skills is most effective,” Kraus suggests.
Geisinger offers a dedicated palliative medicine service and employs several emergency physicians with a strong interest in the topic. “We should continue to strive for widely available, high-quality palliative care service in emergency departments everywhere,” Kraus suggests.
REFERENCE
- Aaronson EL, Petrillo L, Stoltenberg M, et al. The experience of emergency department providers with embedded palliative care during COVID. J Pain Symptom Manage 2020;60:e35-e43.
Although palliative care is integral to providing quality care, in the ED the focus tends to be on aggressive and life-saving measures. More education and training is needed to make ED providers more comfortable with integrating palliative care there.
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