Emergency physicians often feel obligated to order tests and do procedures they don’t believe will help the patient. This is due to a combination of things: fear of litigation, the culture of emergency medicine, and a payment system that rewards tests and procedures over conversations.
Communication skills are as essential for emergency physicians as the ability to demonstrate procedural and disease-specific competencies. But currently, there is no requirement for emergency physicians in training to learn how to negotiate difficult discussions regarding prognosis and treatment decisions, or to demonstrate their ability to advise patients and their families.
This is where palliative care comes in.
Palliative care focuses on relief of pain and other symptoms and emphasizes quality of life. It has been shown to increase patient and family satisfaction, decrease pain and suffering, improve quality of life, and decrease costs.
In our nation’s hospitals, palliative care programs have increased exponentially over the last decade. Still, few programs routinely interact with emergency departments.
Hospice and Palliative Medicine is now an official medical subspecialty, and the American Board of Emergency Medicine is a cosponsoring board. However, the number of board-certified emergency physicians who are also board certified in this subspecialty remains small, though the number is growing.
In fact, growing numbers of emergency providers want to learn more about this discipline. Many of them are seeking and receiving palliative care education and training through programs like Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-EM) and the Harvard Program in Palliative Care Education and Practice.
This training allows them to serve as palliative care champions in their own EDs, in addition to being experts who can pass their knowledge and skills along to trainees. More recently, a number of pilot programs have been developed by palliative care teams to partner with EDs.
You might ask, but how will this help my patients? Increasingly, the typical ED patient is an older adult with multiple chronic conditions who presents not for an isolated acute event, but for an exacerbation of a chronic medical condition. These patients often cycle in and out of the hospital via the ED, and this is a constant opportunity for us to help inform the decisions of patients and families regarding treatment.
For some patients, this may mean confirming the existence of a DNR order or reviewing a Physician Order for Life-Sustaining Treatment (POLST) form, while for others this may involve lengthier discussions with the patient and family.
Palliative care can also help emergency physicians, who experience greater job satisfaction when they learn to better communicate with patients and families.
It is well known that patients and families are more likely to pursue litigation not when they suffer injury, but when they feel ignored or dismissed, or when communication is otherwise poor.
And no emergency physician wants to perform tests and do invasive procedures in patients for whom the risk of harm will exceed the risk of benefit.
Palliative care team presence in the ED will keep growing. The knowledge base and communication skills of emergency physicians are increasing rapidly. This is good for patients, good for families, and in the long run really good for us.
Dr. Grudzen is an Assistant Professor in the Department of Emergency Medicine and Geriatric Palliative Medicine at the Mount Sinai School of Medicine in New York City.
Dr. Bryant is an emergency medicine and palliative care physician at Exempla Saint Joseph Hospital in Denver.