As these three cases illustrate, the context of a patient’s serious illness is extremely important. Finding out where the patient falls on the trajectory of the illness (just diagnosed, end-stage, currently undergoing treatment, bouncing back more frequently to the ED) is crucial in prognostication. Aggressive symptom management ensures patient comfort and family trust in you as the provider and builds a foundation for subsequent conversations. Involving the family early in witnessing resuscitation and communicating prognosis can significantly impact the patient’s course. Exploring the patient’s goals of care, fears, and hopes can also help you make the most appropriate recommendations for the patient and family. The more doctors or providers speak to families and patients about these issues, the more it becomes a normal part of what we do. Even if the family is completely reticent or shut down in distrust or denial, you can suggest a palliative care consult to the primary physician to continue to work with the family and patient beyond the ED.

The authors are members of the ACEP Palliative Medicine Section. Dr. Goett is assistant professor and assistant director for advanced illness and bioethics in the departments of emergency medicine and palliative care at New Jersey Medical School/Rutgers University in Newark, New Jersey. Dr. Fetzer is an emergency medicine attending physician at Advocate Health Care and director of palliative care at Rainbow Hospice and Palliative Care in Mount Prospect and Park Ridge, Illinois. Dr. Aberger is core faculty in emergency medicine and palliative medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey. Dr. Rosenberg is chairman of emergency medicine at St. Joseph’s Healthcare System and associate professor of clinical emergency medicine at New York Medical College.