I am often asked why I decided to do a fellowship in Hospice and Palliative Medicine after practicing emergency medicine for two decades. Was I burned out and trying to escape EM? Was I hoping for a better schedule? Did I want a career alternative for my later years? What I know is that I wanted to add a new aspect to my job and to increase my career longevity. But what truly led to this pivot was a perceived need for advance care planning and better coordination of care for emergency department patients with chronic or serious disease.

While working shifts in the ED, I found myself questioning the appropriateness of resuscitating patients with advanced chronic illness and frustrated with the lack of advance care planning in the medical record. I could see the utility of getting palliative care involved during the ED phase of care instead of several days into a hospital stay. I also envisioned scenarios in which a palliative consult in the ED could avoid an admission altogether and help to facilitate outpatient care.

For these reasons I made it my goal after fellowship to introduce palliative care services dedicated to the ED. An elderly patient presenting to the ED after a cardiac arrest who has obtained return of spontaneous circulation (ROSC) or a patient with end stage disease presenting in extremis are obvious opportunities to discuss code status and treatment limitations with your patient’s surrogate decision maker. However, other scenarios may be less obvious but still present important opportunities for involving the palliative care team. For example, a patient with chronic obstructive pulmonary disease (COPD) presenting with a moderate exacerbation that improves with non-invasive ventilation. Or a patient with pancreatic cancer who comes to the ED for vomiting and dehydration after getting chemotherapy and who might be able to go home after an antiemetic and intravenous (IV) hydration. In both cases, the patients have decision-making capacity and are not in need of resuscitation, so the emergency physician might not see the value in consulting palliative care.

However, to a palliative care physician, these patients are ideal candidates for our involvement in the ED. Both patients may present to the ED in the future in crisis and without prior advance care planning; the next physician is then left managing a patient without knowing their wishes and without a proxy decision maker in place. Emergency physicians might initiate resuscitative efforts that continue in the ICU that may not have been desired by the patient or family. Advance care planning and goals-of-care conversations when a patient with chronic disease is not in crisis can be invaluable to the family and emergency physician when the patient presents later in critical condition.

Even if a patient does arrive in crisis with no advance care planning in place, a palliative care consult in the ED may put the brakes on a path of aggressive care after a conversation with family. And if the patient or decision maker does choose aggressive care in the ED, an early conversation allows them to consider alternatives should the patient not improve.

In addition to goals-of-care discussions, palliative care physicians also manage symptoms such as pain, nausea, and dyspnea that result from chronic illness or therapies. A palliative care consultant in the ED can potentially prevent the admission of a cancer patient with increased pain by starting or modifying pain medication, for example. Hospice referral from the ED may avoid admission or decrease an inpatient length of stay. And if the patient is not quite ready for hospice, a palliative care consult serves as an opportunity to introduce the hospice philosophy and options for the future.

Despite how useful palliative care consultation can be in the emergency department, only 3 percent of palliative care consults are initiated by emergency physicians. Although many hospitals have a palliative care consult team, very few have a consultant dedicated to the ED. Initiating an embedded palliative care consultation program in the ED takes support from both departments.

At first, many of my EM colleagues did not see the immediate value of consultation in the ED because it does not always affect their patient management during that visit. It has therefore been an ongoing process to educate emergency physicians on how a palliative consult on the current visit could be useful, if not to their care today, then during their inpatient stay or a future ED visit. Although palliative care involvement is initiated by the ED physician more frequently, even when I am not present, I am still often suggesting the consult.

Early initiation of palliative care consultation from the ED has been shown to reduce length of stay and decrease hospital costs. For patients who get admitted, a palliative care discussion while in the ED facilitates earlier clarification of inpatient goals and treatment limitations. A study by Wang et al. demonstrated an 8.1-day shorter hospital length of stay for patients admitted to the floor after a palliative care consult from the ED compared to when the order was placed after admission, and a 4.2-day shorter length of stay for patients admitted to an ICU.¹ The median cost savings were $5,974 and $9,332, respectively, for floor and ICU patients if the palliative consult occurred in the ED as opposed to after admission. Other studies have reported similar findings.^2,3,4 Additionally, an ED-based consultation may lead to alternative care destinations, such as home or inpatient hospice, or follow-up with outpatient palliative care services. Despite the potential benefits, there are several obstacles to an embedded EM palliative care program. It is unlikely that any program will be available 24/7/365. Additionally, ED boarding and diversion can make the embedded palliative consultant’s time less productive.

Hopefully more health care systems will recognize the utility of dedicated palliative care programs for the emergency department. As an increasing number of emergency physicians are completing fellowships in Hospice and Palliative Medicine, there will be a well-suited workforce to fill this role. And if such a program does not exist in a practice location, emergency physicians should forge relationships with the inpatient palliative care consult service and consider involving them in the care of their patients. Palliative care conversations can also occur by telemedicine for smaller hospitals who may not have their own palliative care team.

Allison Tadros, MD, FACEP, is a professor in the West Virginia University Department of Emergency Medicine and the Division of Geriatrics, Palliative Medicine and Hospice in Morgantown, WV. She is dual board-certified and practices clinically in both emergency medicine and palliative medicine. Her clinical and research focus is on providing palliative care in the emergency department setting. She serves as the co-secretary for the ACEP Palliative Medicine Section.

Justin K. Brooten, MD, FACEP, is an assistant professor of Emergency Medicine at Wake Forest University School of Medicine at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. He is Program Director of the Hospice and Palliative Medicine Fellowship and is dual board-certified in Emergency Medicine and Hospice & Palliative Medicine. Clinically, he practices in both the emergency department and inpatient palliative care and serves as Chair of the American College of Emergency Physicians (ACEP) Palliative Medicine Section.

Correction: The original byline for this article was incorrectly attributed to ACEP Now Medical Editor-in-Chief Cedric Dark, MD, MPH, FACEP, but has been updated with Dr. Tadros’ and Dr. Brooten’s bylines. ACEP Now regrets the error.

References

1. Wang DH, Heidt R. Emergency Department Embedded Palliative Care Service Creates Value for Health Systems. J Palliat Med. 2023;26(5):646-652. doi:10.1089/jpm.2022.0245.
2. Wang DH, Heidt R. Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs. J Palliat Med. 2021;24(4):554-560. doi:10.1089/jpm.2020.0082.
3. Denney CJ, Duan Y, O’Brien PB, et al. An Emergency Department Clinical Algorithm to Increase Early Palliative Care Consultation: Pilot Project. J Palliat Med. 2021;24(12):1776-1782. doi:10.1089/jpm.2020.0750.
4. Wilson JG, English DP, Owyang CG, et al. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2020;59(2):372-383.e1. doi:10.1016/j.jpainsymman.2019.09.020.