Findings underscore value of palliative care
Experts: Begin goal discussions earlier
There is new evidence that initiating palliative care consults in the ED results in shorter hospital lengths of stay (LOS) than when palliative care consults are not provided until after admission. Researchers looking specifically at the impact of earlier palliative care consults report that in an analysis of 1,435 palliative care consults, 50 of which took place in the ED over a four-year period, consultation in the ED was associated with hospital stays that were 3.6 days shorter, on average, than the hospital stays of patients who received palliative care consults following admission.1
While the study is small, it reinforces the observation that the longer palliative care consultation is delayed the less impact it has, explains Abraham Brady, RN, PhD, GNP-BC, an assistant professor at New York University College of Nursing in New York City, and a co-author of the study. "There are certain patients who come into the ED who really should have been seen by palliative care [clinicians] sooner," he explains. "If we start their [palliative care consult] in the ED rather than waiting until they are up on the floor or in the ICU [intensive care unit], we might be able to improve their quality of life or quality of care within the hospital and meet their needs and goals better."
What should trigger a palliative care consult in the ED? In the study, the mechanism was fairly straightforward, explains Brady. "We gave every provider within the ED, both physicians and RNs, a set of guidelines for patients who would be appropriate [for a palliative care referral]," he says. "Providers could refer patients outside of that set of guidelines, but the guidelines focused on the groups of patients we believe are seen most heavily in the ED."
For instance, patients with metastatic cancer, advanced congestive heart failure, advanced chronic obstructive pulmonary disease, or advanced dementia were candidates for palliative care consultation, says Brady. "These are probably the four top groups of patients who can best use goals-of-care discussions, quality-of-care discussions, and other quality-of-life services offered by palliative care teams," he adds.
Focus on goals of care, patient needs
The aim of palliative care is to be holistic, to improve the quality of life of patients, and to meet the needs of patients and their families; consequently, a palliative care consult needs to include several components, explains Brady. "The palliative care provider will have an extensive goals-of-care discussion with the patient or a family member to try to ascertain what the needs of the patient are," he says. "The provider will also make sure that the patient's symptoms are managed appropriately, and then they will bring in other areas of care."
For instance, many palliative care teams have chaplains or other spiritual advisors, and some have social workers or psychologists involved as well. Also, many palliative care teams are led by nurses or nurse practitioners rather than physicians. "The overall goal of this comprehensive team is to help make sure that the patient's needs are met, so it is all about patient-centered care, and making sure that the patient has their needs met rather than the health system having its needs met," says Brady.
When patients present to the ED, for example, one goal of the ED clinicians is to get the patients out one way or another to make way for incoming patients, explains Brady. "Whether a patient is discharged or sent up to the ICU or one of the other medical units of the hospital, that is the traditional pathway," he says.
However, the traditional pathway is not always the best or the preferred approach for some patients, says Brady. For instance, he recalls the case of a patient with advanced dementia who could have been admitted to the hospital. "That would have been the easy way to go," he says. "But the palliative care team involved was able to arrange for the patient to go directly back home with home hospice services to prevent an admission to the hospital and ensure that the patient was cared for in the setting he wanted," he says.
Integrating palliative care into the emergency setting isn't always an easy fit, says Brady. "The way the business model is set up within an ED is that you have to get the patients out the door into a more appropriate environment, whether that is the home environment or the hospital," he says. "At the same time, however, ED physicians and nurses get very frustrated when they see the same patients returning again and again."
Consequently, while there can be some resistance to palliative care in the emergency setting, Brady observes that emergency clinicians may also see palliative care services as being a solution for some of the patients who frequent the ED, but do not necessarily require emergency care. "Emergency clinicians don't want to see patients coming back again and again for a heart failure exacerbation - something that should be managed in an outpatient setting, so there is some buy-in [for palliative care consults in the ED]," adds Brady.
However, even when there is ample buy-in, the availability of on-site palliative care clinicians is less than optimal. In the study, there were many patients who met the criteria for palliative care consults, but they were not referred, explains Brady. "A lot of these cases were on nights and weekends when there was no palliative care coverage . so one of the biggest barriers was that there wasn't 24/7 on-site availability of palliative care team members in the hospital," he says. "Most palliative care teams have 24/7 coverage in that someone is available by phone, but most do not have a 24/7 presence in the hospital."
Given the significantly reduced LOS of patients who received palliative care consults, it is possible that it would be cost-effective to provide 24/7 on-site palliative care coverage in the ED, acknowledges Brady, but he notes that studies need to be done that show this is the case.
Another barrier is the dearth of clinicians equipped with palliative care training. "We can just about meet the needs in the inpatient setting, but as we move into having more and more palliative care clinicians in the outpatient setting, that is something where we don't have enough training slots to meet those needs," explains Brady.
Identify palliative care resources
The American College of Emergency Physicians (ACEP) is fully on board with efforts to integrate palliative care treatment options into the treatment of appropriate patients who present to the ED with chronic or terminal diseases. In October, ACEP cited the early introduction of palliative and hospice care services as one of the organization's five top recommendations as a co-sponsor of the "Choosing Wisely" campaign, a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation aimed at promoting conversations among physicians and patients about the appropriate use of tests and procedures, and avoiding care when harm may outweigh the benefits.
"Palliative care has risen to the top of the radar screen for emergency medicine," says Tammie Quest, MD, an emergency medicine physician and director of the Emory Palliative Care Center for Emory University's Woodruff Health Sciences Center in Atlanta. "What has happened is a growing awareness of the role of palliative care and end-of-life support services."
While it is not clear how many EDs thus far have integrated palliative care into their service options, Quest stresses that when emergency clinicians have resources such as palliative care units, consultants, or hospice services available to them, they will use them. "Culturally, the field is very open to change. Emergency medicine is one of the most flexible and adaptable specialties," she says. "My own experience is that when you teach emergency providers what the resources of palliative care are, either by them learning additional skills themselves or by utilizing skills that may be in a system, there is very good uptake of these skills and/or resources."
Find a champion
At Emory, there is no formal list of triggers to prompt an emergency provider to call for a palliative care consult. "After more than a decade of education between our residents and faculty, we have very good emergency clinicians who can recognize the need for palliative care in seriously ill patients," says Quest. "More than 10% of admissions to our hospice unit are sent directly from the ED, so our emergency providers here are very good at goals-of-care conversations and assessment of patient and family needs, so they will often call with people who they feel are appropriate."
However, in systems where primary palliative care may not be as rich, it can be helpful to have a palliative care specialist available to emergency clinicians when they have a patient who could benefit from palliative care services. In fact, Quest is director of Improving Palliative Care in Emergency Medicine (IPAL-EM), an effort to equip EDs with the tools and knowledge required to improve palliative care in emergency settings. She advises administrators to begin the process with a needs assessment.
"Sit down with a group of people who are in the ED, figure out where the greatest need is, and find an ED champion," says Quest, noting that the needs assessment form is just one of a number of tools that are available free of charge through the IPAL-EM website, which is operated by the Center to Advance Palliative Care (www.CAPC.org), headquartered at the Icahn School of Medicine at Mount Sinai in New York City. "You need an ED champion who will peel the onion back layer by layer, and just take a deeper look to determine, of all the things that need to be done, what really needs to be prioritized."
Once palliative care priorities are established, you can create an action plan for how to achieve them, says Quest. "I would suggest that emergency clinicians reach out to their hospital-based palliative care services or their community hospice providers to see what partnerships can be forged to get their needs met."
Consider new payment models
Accountable care organizations (ACOs) and other new payment models that reward quality and efficiency are likely to focus more attention on the benefits of palliative care. In the case of ACOs, for example, providers who are successful at keeping patients out of the hospital and the ED are able to share in the savings that result from the avoidance of unnecessary, expensive care. "Similarly, if patients go on hospice earlier, that saves money because in order to get the full benefit of hospice you need [patients in the program for] 50 to 100 days at least. And right now, patients are in hospice for about seven days, on average," says Brady.
Another positive financial impact comes from the avoidance of the penalty Medicare imposes on hospitals that have elevated readmission rates. "Palliative care teams have been shown to reduce readmission rates," adds Brady.
While financial considerations are not what drive decision-making in palliative care, the model is aligned with an ACO's emphasis on better resource utilization and better outcomes, says Quest. The decreased costs and more effective use of resources do not come from withholding care, but rather by aligning patient-centered goals around whatever the care and treatment options are, she says. "I think that the way palliative care stands to benefit emergency care providers, patients, and ACOs is really by consistently using patient-centered models of assessing what patient goals of care are, what the outcomes and perceived expectations are from the patient and family, and what we are clinically able to deliver."
- Wu F, Newman J, Lasher A, Brody A. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. Journal of Palliative Medicine 2013;16:1362-1367.