The terminally ill and those with serious chronic illness traverse the emergency department many times throughout their illnesses. The emergency department is an important resource in the continuum of care. It is where people go when their symptoms are uncontrolled or they are unprepared for the impact of serious disease on their lives. Seriously ill patients are a large and growing population of patients in emergency departments nationally.
In light of this, emergency medicine is increasingly incorporating palliative care (PC) into its service lines and educational programming. These efforts target the arms of the quadruple aim: better patient outcomes and reduced cost, as well as improved patient and provider experiences. Models delivering PC services in the emergency department run the gamut from fully integrated PC services led by the emergency department itself to strategic educational partnerships with existing palliative provider teams.
ACEP’s Palliative Care Section recently discussed these developments with Christian Sinclair, MD, assistant professor of palliative medicine at the University of Kansas in Kansas City, president of the American Academy of Hospice and Palliative Medicine (AAHPM), and editor of the website Pallimed.org.
Section: ACEP’s leadership recently initiated conversations with AAHPM about best practice guidelines for PC’s role in emergency medicine. Can you share any updates on these discussions?
CS: At AAHPM, we’re seeing there is a core skills set and knowledge base for providing PC in the ED. This is called “primary” or “generalist” palliative care. There are unique aspects in delivering PC in the ED that are different than an outpatient center or intensive care unit. Part of a strong approach to PC in the ED is understanding what the systems and delivery issues are. Then we need to figure out what core elements from PC are useful there. Any partnership needs to take into account the unique system aspects of the ED.
Section: Where do you see the ED evolving in the future as far as the continuum of care for palliative patients?
CS: There are a lot of EDs that have gotten good at saying, “We can have these tough conversations; we can change to goals of care that fit the patient’s preferences and get someone admitted to inpatient hospice without admitting them first to the hospital.” This is great.
However, there are a lot of patients who fall in the gap between not meeting criteria to be admitted to the hospital and not being safe for discharge home. These patients need sophisticated support, but they’re not ready for hospice.
PC, as a field, is really moving toward outpatient and community-based care. With new community initiatives that we’re seeing from PC, the ED will have new and better options [for palliative patients]. We’re hoping to prevent [avoidable] ED visits by getting to people before they get into a crisis. That being said, what we hope to see is more intensive community-based PC, giving the ED more options to get PC patients back to their homes if that is the patient’s preference.
Section: Emergency medicine providers obtaining formal training in PC are a rapidly growing cohort. What do you see as the role of formal training in palliative medicine for emergency medicine?
CS: PC is a unique specialty with 10 different boards that feed into it. There’s a lot to be said at any institution or hospital for having someone in the ED who can be a palliative care champion. That person not only speaks the language and understands the culture of the ED but also the culture of PC. They act as a bridge. I think having someone who can be a champion, speak both languages, and understand both cultures will allow for implementation to happen in a much smoother fashion.
The AAHPM meeting was in February in Phoenix. We’re always interested in talking to people outside the classic palliative medicine/internal medicine dyad. There is an EM special interest group, too.
Dr. Tammie Quest is an emergency physician and is the incoming president for AAHPM in 2018. It’s an exciting time!
The ACEP Palliative Care Section members who contributed to this interview are:
Kate Aberger, MD, FACEP, core faculty, emergency medicine/palliative medicine, for St. Joseph’s Regional Medical Center in Paterson, New Jersey, and chair of ACEP’s Palliative Medicine Section.
Marny Fetzer, MD, palliative care medical director at Rainbow Hospice and Palliative Care in Illinois.
Rebecca Goett, MD, assistant professor of emergency medicine and assistant director for advanced illness and bioethics at Rutgers New Jersey Medical School.
Mark Rosenberg, DO, MBA, FACEP, chairman of emergency medicine, chief of population health, and associate professor of clinical emergency medicine for St Joseph’s Healthcare System in New Jersey and a member of ACEP’s Board of Directors.