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.