By Victor Montour
Patients with a serious illness are likely to find themselves in an emergency department (ED) at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. In the last five years, emergency medicine has increasingly taken a central role in the early implementation of palliative care. Widespread integration of palliative care into the day-to-day practice of emergency medicine, however, is often jeopardized by the demands of many competing priorities.
Although the ED is not considered an ideal place to begin palliative care, hospital-based physicians can assist in eliciting the patient’s goals of care and discussing prognosis and disease trajectory.
There has been and continues to be a large movement to educate emergency physicians on end-of-life care and improve palliative care in emergency medicine, leading to clinical practice guidelines. In reality, because of the acute symptoms that are often accompanied by significant emotional overtones and disposition issues, an emergency medicine physician, hospitalist or intensivist should quickly contact a community based palliative care team for consultation. Many patients present with serious and unrelieved symptoms such as pain, dyspnea, nausea, and vomiting that were not well controlled in the outpatient setting without a community based palliative care program involved. The ED or hospital may be the only option for them to receive intravenous (IV) fluids or medications, as well as immediate access for acute imaging or access to specialists, for example, radiation oncologists. Even if the patient’s goals are clearly non-aggressive, the patient may arrive in the ED because of family distress over uncontrolled symptoms.
Emergency room physicians are in a unique position to have early conversations can help with the identification of patients who may need palliation, discussing prognosis, eliciting goals of care and directives, symptom management in the ED, and making plans for further care. These efforts have been shown to improve outcomes and to decrease length of stay and cost in the hospital setting. The focus of palliative care is relieving “patient” symptoms and family distress, honoring the patient’s goals of care, and assisting in transition to a supportive approach and placement where this may be accomplished in the most conducive environment for the patient and family.
Front Range Hospice and Palliative Care has vast experience working with emergency room physicians and staff to meet the symptom management needs of patients in the communities we serve. If you or someone you know finds themselves in the emergency room, remember to ask the doctor to make a referral to Front Range Hospice and Palliative Care for palliative care services.
Characteristics of Patients Needing a Palliative Care Consult:
- Patients with a serious, life-threatening illness and one or more of the following need a palliative care consult.
- Bounce-Backs – The patient makes more than one ED visit or hospital admission for the same condition within a few months
- Uncontrolled Symptoms – ED visit is prompted by difficult-to-control physical or emotional symptoms.
- Functional Decline -There is decline in function or worsening of feeding intolerance, unintentional weight loss, or caregiver distress
- Increasingly Complicated – Complex long-term care needs require more support.
Other patients that may benefit from early hospital medicine or palliative care consult include transfers from a long-term-care facility; patients with metastatic or locally advanced, cancer; patients with out-of-hospital cardiac arrest; advanced dementia patients; and frail, elderly patients with poor functional status.
Adults with chronic illnesses often visit an ED several times in their last year of life. A study of patients older than age 65 years by Smith et al revealed 75% visited an ED in the last 6 months of life and 51% in the last month, many with repeat visits. The transition community based palliative care, symptom management may greatly change the hospital trajectory of care. Here is the opportunity to initiate further goals of care that may change future plans. Research supports early palliative care in the ED to improve quality of life as well as to reduce costs that may have been associated with alternate treatments. Discussions surrounding goals and plan of care, symptom management, and aggressive pain control are some of the cornerstones of palliative care. Some additional benefits from early palliative care interventions in the ED include resource management, improved satisfaction for patients and their families, improved outcomes, decreased length of stay, less use of intensive care units and less cost, and increased appropriate direct hospice consults.
Goal-Oriented Patient Assessment
A goal oriented patient assessment is the first imperative step to find out why the patient is in the ED and to perform a rapid assessment of their palliative care needs. Emergency medicine physicians can begin goal-directed assessments and plans that can help avoid unwanted treatments, inappropriate resource expenditure, and undue suffering.
For more information about Front Range Hospice and Palliative Care and our Palliative care program call 303-957-3101 or 970-776-8080 or email us at firstname.lastname@example.org