“Most patients’ palliative needs can and must be addressed by medicine’s frontline providers: Emergency physicians.”
—David H. Wang, MD, Annals of Emergency Medicine
Because physicians in emergency departments (EDs) frequently encounter patients with life-limiting illness who present with challenging complaints, they have the opportunity to recognize what may be overlooked in routine office visits—that a patient would benefit from palliative/hospice care, according to an article published in Annals of Emergency Medicine, the official publication of the American College of Emergency Physicians (ACEP).
“The ED has a unique opportunity to serve as a hub for unmet palliative care needs,” writes David H. Wang, MD, an emergency medicine and palliative care physician practicing in the San Francisco area. In the article, Wang offers emergency physicians quick and practical tools for assessing needs and implementing palliative care in the ED.
Early palliative care has been shown to reduce ED visits and hospitalizations by as much as 50% across settings and disease populations, points out Wang. Palliative care—of which hospice and comfort care are components—is “a win-win for patients and for healthcare systems,” he writes. “Rather than being ‘another thing for emergency physicians to do,’ intervening early for these patients has a palpable effect on lives.”
While the percentage of US hospitals with palliative care programs has been increasing in recent years, the number of specialists in palliative medicine is not sufficient to meet patient needs, notes Wang. Thus, “Most patients’ palliative needs can and must be addressed by medicine’s frontline providers. Emergency physicians must now develop ‘primary palliative care’ expertise unique to their practice climate.”
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Components of a Palliative Care Assessment
Prognosis. “Although comprehensive screening tools are being developed and validated, perhaps the single easiest and most predictive tool remains the question, ‘Would I be surprised if this patient dies in the next 12 months?’” writes Wang. Although not yet validated in the ED setting, this tool has potential to be actionable in a time-limited setting, he notes.
Goals of care. Keeping in mind the time constraints and competing distractions of a busy ED, Wang provides a simple, five-minute framework for holding a goals-of-care discussion. This “crucial discussion” is as much about acquiring a sense of the patient’s/family’s emotional drivers as it is about information exchange, notes Wang, explaining that “families are better equipped to collaborate around ‘goals’ rather than specific interventions.”
Five-minute goals-of-care discussion in the ED
- Elicit patient understanding of underlying illness and today’s acute change.
- If available, build on previous advance directives or documented conversations.
- Acquire sense of the patient’s values and character, to help frame prognosis and priorities for intervention.
- Name and validate observed goals, hopes, fears and expectations.
- Discuss treatment options, using reflected language.
- Continually re-center on patient’s (not family’s) wishes and values.
- Recommend a course of action, avoiding impartiality when prognosis is dire.
- Summarize and discuss next steps.
- Introduce ancillary ED resources (e.g., hospice, observation, social work, chaplain).
Suggested supportive phrasing
Physicians can help families/surrogates understand options and make care choices by being aware of the importance of word choice and intentionally selecting alternatives to commonly used phrases, Wang suggests. “Given the significant information asymmetry between providers and patients, word choice is critical when options are being presented.”
- Instead of “Do you want us to do everything possible?” physicians can ask, “What is most important to [name] right now?”
- Instead of “Would [name] want heroic measures?” physicians can ask, “What was [name] like before the illness?”
- Instead of “I wouldn’t want this for my mother,” physicians can say, “Tell me about your mother.”
- Instead of “Do you want us to push on your mother’s chest, use electricity, and provide her with a breathing machine?” physicians can ask, “Based on what you’ve told me about her, do you think she would want to die a natural death?”
- Instead of “There is nothing more we can do,” physicians can say, “We will aggressively make [name] comfortable.”
Options for disposition from ED to palliative/hospice care include:
- Early outpatient palliative care referral
- Inpatient palliative care consult
- Direct ED-to-hospice discharge
- Discharge to inpatient hospice bed, if available, for patients whose symptoms cannot be adequately controlled at home
- Short-stay private room for imminently dying comfort-care patients
“Palliative care begins in the ED and bridges into inpatient and outpatient services,” concludes Wang. “Current momentum hinges on greater education and research. Historically, emergency physicians have prided themselves on being first-movers. Now is the time to own the change.”
Source: “Beyond Code Status: Palliative Care Begins in the Emergency Department,” Annals of Emergency Medicine; April 2017; 69(4):437-443. Wang DH; Department of Emergency Medicine, Stanford University, Stanford, California; and Division of Palliative Medicine, University of California-San Francisco, San Francisco.