In other words, while hospice care falls within palliative care, not all palliative care patients are at the end of life. One of the key concepts in palliative care for patients with chronic progressive illnesses is replacing the traditional all-or-nothing approach – exhausting all diagnostic and therapeutic measures and then sending a patient to hospice in the final days of life – with an approach that gradually transitions over time from an emphasis on life-prolonging measures to a focus on comfort.

The American Academy of Hospice and Palliative Medicine (AAHPM) states that the purpose of palliative care is to “prevent and relieve suffering and to support the best possible quality of life for patients and their families regardless of the stage of the disease or need for other therapies; [palliative care] can be delivered at the same time as life-prolonging care or as the main focus of care. [It is] achieved through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and cultures.”

All emergency department patients, especially those approaching the end of life, should expect skillful management of distressing symptoms. Symptom management is a cornerstone of palliative care and in many settings is the primary role of a palliative care service. Pain control is the most obvious area of symptom management and one where the typical emergency department practice can present challenges.

Emergency physicians order and prescribe opioid and non-opioid analgesics routinely. At the same time, these physicians are often confronted by patients who misuse or divert pain medications and “shop” from emergency department to emergency department, making physicians reluctant to prescribe large amounts. Further, emergency medicine training cautions physicians to avoid respiratory, cardiovascular, and mental status complications that can result from excessive dosing of acutely ill and often unstable patients.

And yet patients with advanced illness, particularly patients with advanced cancers, can have extraordinary analgesic needs, requiring doses that would unnerve many physicians (not to mention nurses confronted with these orders). A “routine” dose of 4 mg of IV morphine in a patient normally on the equivalent of 400 mg of oral morphine a day is unlikely to do much for such a patient in a pain crisis.

for some emergency physicians, palliative care represents an opportunity to develop an additional skill set.

Opioid dosing and conversions, use of adjunct and non-opioid medications, and management of side effects are all key skills for specialists in palliative care. In addition to pain, symptoms commonly managed by palliative care providers include dyspnea, nausea and vomiting, constipation, diarrhea, delirium, and anxiety and depression.