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.