Identifying patients who will benefit from palliative intervention, referring them to palliative care or hospice services, and managing symptoms are key to helping patients meet their end-of-life goals
It is 8 p.m. on a Thursday, and you go in to see a 78-year-old woman with pancreatic cancer and a chief complaint of a blocked surgical drain and fever. You walk into the room and see a pleasant elderly woman in no apparent distress, although she is slightly confused. Her anxious son and daughter-in-law are at her bedside. They are insisting that the GI specialist come immediately to the emergency department to see their mother, whom they say is clearly more jaundiced. They also want the blocked surgical drain repositioned. Next week, the patient is going to a large referral hospital for a new Gamma Knife treatment regimen for pancreatic cancer. After your evaluation, you call the GI attending, who states there is nothing to do and, really, this patient should be in hospice care. You agree. What are your next steps?
The emergency department has a unique role in the decisions related to palliative and end-of-life care. In fact, this was addressed by the “Choosing Wisely” campaign, as announced by the ACEP Board of Directors for the American Board of Internal Medicine (ABIM) during the ACEP13 Scientific Assembly. One of the five key “Choosing Wisely” focus points for emergency physicians and emergency departments is to refer appropriate patients to palliative medicine and hospice services: “Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.” Additionally, the American Board of Emergency Medicine (ABEM) is 1 of 10 sponsoring boards for the hospice and palliative medicine subspecialty.
Each year, one out of four Medicare dollars is spent by just 5 percent of the beneficiaries in the last year of life, to the tune of $125 billion.1 Consider that people die in one of four ways: sudden death, terminal illness, organ failure, or dementia/frailty. In the United States, 6 percent die from sudden death, with the other three categories eligible for palliative or hospice care. The vast majority of people want to die at home, yet only 17 percent do. More than 70 percent of people die in a health-care facility, and most of them are admitted through the emergency department.
The emergency department and the emergency physician clearly play crucial roles in the delivery of palliative and end-of-life care. To clarify, palliative is non-curative symptom management of serious or terminal illness and can be given in conjunction with curative treatment. Hospice care is when curative treatment is no longer beneficial and treatment is to manage symptoms only. The emergency physician, as the team leader, has a tremendous opportunity to aid patients to die in a better way. So where do you start? There are four key elements in the emergency department: identification of patients, having the conversation, symptom management, and the role of hospice.