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?
Explore This IssueACEP Now: Vol 33 – No 01 – January 2014
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.
To achieve this, we need to better understand which patients should receive these services. Consider the following case:
A 54-year-old male presents to the emergency department with stage-4 lung cancer, a history of metastatic disease to the brain, and a complete white out of the right lung secondary to tumor and effusion. He was identified as needing a palliative consultation by the emergency-department palliative care triage-screening tool. The palliative team, consisting of the emergency physician and palliative registered nurse, saw the patient and family in the exam room. The conversation was started by asking the patient what he thought was going on. His sister answered that he was dying. “There is nothing more to be done, but he is so short of breath and uncomfortable,” she said. The patient continued to nod his head in agreement. The palliative team asked if they could partner with the patient and his sister to develop a plan. Together, the palliative team, the patient, and his family developed a plan. This patient was sent in by his doctor for hospital admission; however, during the discussion, it was discovered that one of the patient’s goals was to spend as little time as possible in the hospital. The team agreed that this partnership would manage the patient’s symptoms and notify the hospice case manager to see if he was the right fit to help the patient manage his illness at home with his family. Within four hours, his dyspnea was relieved and he was admitted to inpatient hospice for stabilization. That would give everyone time to prepare so that he could go home for his final days. Two days later, he was home with his family and pet cat.
This is not an unusual case to present to the emergency department. As a matter of fact, this is the type of patient most emergency departments in the country see every day. This emergency department may be unique in that they have hospice/palliative medicine–certified emergency physicians on call 24-7 for palliative consults.
In this case, there are several key elements to a palliative referral, which can be achieved using in-house or community resources. The key elements when considering referral of seriously ill patients are to identify patients who can benefit from palliative intervention, know how to have the conversation, be the best symptom manager, and understand the role of hospice and palliative services.
Palliative medicine is the newest frontier in EM. ED visits are the logical place and time; a new skill for EPs in 2014 and beyond.
Key Element #1: Identification of Patients
Screening tools have successfully been used in triage for many aspects of emergency-department care. A tool that can easily be adapted for triage screening is a simple yes-or-no question: “Would you be surprised if this patient died within the next six months?” Any patients who have a serious illness with a possible death within six months are candidates for a palliative discussion. This is the critical first step, whether initiated by the emergency physician or the consult.
Key Element #2: Having the Conversation
The initial case presentation of the 78-year-old woman with pancreatic cancer illustrates a potential candidate for palliative care and possibly hospice. How do you start the discussion? A shift in demeanor for the emergency physician is required. Take the time to connect with patients and their families. Sit and have a one-on-one intimate conversation; this can be facilitated by the emergency physician or the consult.
The conversation should not be about end-of-life care or do-not-resuscitate orders. The discussion should follow some simple guidelines:
- Introduction. Introduce yourself and state the reason for your questions.
- What’s happening. Ask patients and their families what they think is going on with their illness. Do they think they are getting better or worse? Simply opening this dialogue first helps you gather more information and may lead to the quick agreement that a person is dying. To our amazement, many patients or family members say, “I think I am dying,” or “I don’t think I will survive this.”
- Goals. The next focus is on exploring patients’ care goals and life goals. This allows you to change the conversation to what you, as a clinician, can do to support patients’ decisions. If they haven’t thought about this, a simple lead-in conversation, such as, “Let’s discuss planning for the worst and hoping for the best,” opens the discussion. Having this type of meeting and discussion is easier than you might imagine.
- Partnering. Rather than focusing on the traditional “all or none” divisive conversation, this changes the tenor of the conversation to a planning exercise with the emergency physician as a partner. Through this approach, the emergency physician in the initial case was able to guide the family to consider hospice and tone down acute aggressive treatment. However, sometimes this conversation may go nowhere due to reasons beyond your control, such as symptom severity or family members not being present. Remember, it is about patients’ goals—not yours.
- Palliative referral. A referral to your palliative services may be all that is needed so a family meeting can take place at a more appropriate time.
Key Element #3: Symptom Management
If patients want everything done, then consider time-limited interventions or therapy. A family meeting to discuss goals of care can be set up for the future.
This is one of the most important areas of palliative medicine in the emergency department and something we do every day. For all patients and families we see, we must be skilled in managing all physical, psychological, and spiritual symptoms, including pain and non-pain symptoms. Pain algorithms and guidelines exist, with conversion tables to control and alleviate pain. Other non-pain symptoms, such as dyspnea, nausea and vomiting, diarrhea, delirium, constipation, and anxiety, frequently need management and stabilization. The emergency physician must master this skill and knowledge.
Key Element #4: Role of Hospice
A branch of palliative care, hospice is a Medicare benefit that provides patients with terminal illness a complete care program, which includes nursing support, physical therapy, psychological support, and durable medical equipment. Hospice is frequently thought of for those who are terminally ill with cancer, but it is a welcomed adjunct for a son or daughter struggling with a parent with dementia. With the help of hospice, patients can frequently be managed at home instead of in a nursing home. Hospice is a total-care system that is designed for terminally ill patients likely to die within the next six months. It can be provided in any location, including one’s home or a nursing home.
The role of emergency-department palliative care is to support life-sustaining management and alternatives and to allow patients to approach death and dying on their own terms, with comfort and control, while maintaining their dignity.
- Hogan C, Lunney J, Gabel J, Lynn J. Medicare beneficiaries’ costs of care in the last year of life. Health Aff (Millwood). 2001;20:188-195.
Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, is chairman of the Department of Emergency Medicine, chief of Geriatrics Emergency Medicine, and chief of Palliative Medicine at St. Joseph’s Healthcare System in Paterson, N.J.
Rebecca Parker, MD, FACEP, is executive vice president for EmCare’s North Division; attending emergency physician at Presence Covenant Medical Center in Urbana, Ill., and Centegra Health System in McHenry and Woodstock, Ill.; clinical assistant professor at Texas Tech University-El Paso; and an ACEP Board member.