The emergency department provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease.
Until recently, palliative-care services have been largely unavailable in emergency departments. However, in the past decade, there has been growing recognition from both the EM and palliative medicine communities on the importance of palliative-care provisions in the ED.
The past 10 years have seen a surge in EM–palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative-care practices.
Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high-quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative-care provisions on patients with serious illness in the ED.
The aging of our population results in the growing number of patients living with serious illnesses. Unsurprisingly, these patients often present to the emergency department, especially toward the last stages of their illnesses. In fact, over half of older adults will visit the ED in the last month of life.
Most patients with serious illnesses report that they prefer medical therapies that minimize pain and suffering, and maximize their time at home. Importantly, most prefer to avoid aggressive therapies that have low likelihood of promoting, sustaining, or improving quality of life, such as CPR and intubation.
However, the traditionally dominant paradigm in emergency medicine is to maintain life at all costs. Consequently, many older patients spend the last months of their lives coming in and out of the ED. Additionally, the aggressive high-cost, low-quality, end-of-life (EOL) care has a significant financial burden.
The changing realities of our patient population should prompt us to adapt our practices and focus on patients’ goals and preferences when providing treatment. The integration of EM and palliative care is an essential part of making the necessary changes.
In 2003, ACEP released a statement directing emergency physicians to improve EOL care by developing communication skills and clinical approaches targeted to the needs of patients with serious illness. At the time, there were limited palliative-care education, training, and guidelines to support emergency physicians as they provided care to patients. The statement from ACEP gave rise to numerous projects aimed at improving palliative care in the ED.
Research efforts during this time revealed significant benefits to palliative care in the ED, including improved hospital outcomes, reduced hospital length of stay, improved patient satisfaction, and cost savings.
In 2006, hospice and palliative medicine (HPM) officially became a subspecialty in medicine, and EM was one of 10 specialties allowed to pursue HPM as a subspecialty. This increased interest among emergency physicians to become dual board-certified in EM and HPM. In 2012, ACEP released its “Choosing Wisely” recommendations, which further emphasized the importance of integrating palliative care into EM. These events from 2003-2012 accelerated changes in EM practices and encouraged more widespread adoption of palliative care in the ED.
With the number of people living with serious illness expanding, the ongoing shortage of clinicians with palliative-care training continues is concerning. Because the imperative to educate the EM workforce has only recently been established, most practicing emergency physicians have not been exposed to adequate palliative-care training.
Fortunately, more educational and training opportunities in palliative care have been developed specifically for emergency physicians. These include the Center to Advance Palliative Care’s (CAPC) Improving Palliative Care in Emergency Medicine (IPAL-EM) program and Northwestern University’s Education in Palliative and End-of-Life Care (EPEC-EM) program. Currently, five states require physicians to participate in palliative continuing medical education credits.
The presence of palliative-care training for EM residents varies across the country. A study in 2012 showed that 88% of EM residents agreed that palliative-care skills are an important area of competency, but roughly half of them reported having minimal training in palliative care. A common barrier was the lack of palliative expertise among teaching faculty. Most EM programs tailor their teaching to address the content of American Board of Emergency Medicine (ABEM) examinations, but only a handful of questions are related to palliative care.
Importantly, dual board-certified EM/HPM physicians have served critical leadership roles in spearheading training and quality improvement initiatives to respond to increased palliative-care needs in the ED. Quality improvement initiatives have mostly focused on improving patient access to palliative care through improving skills in emergency physicians and identifying patients who could benefit from such care.
Researchers have determined that one of the most effective methods of palliative-care screening in the ED is through tools such as Palliative Care and Rapid Emergency Screening (P-CaRES) and Screen for Palliative and End-of-life care needs in the ED (SPEED). Even quick and easy tools — for example, the “surprise question” worded as, “Would you be surprised if your patient died in the next one month?” — have proven useful in identifying patients near the end of life.
Palliative-care implementations in the ED and their effects are a growing area of research studies. Advance care planning (ACP) is an important focus area within palliative care in the ED and presents a significant opportunity to engage with patients. Studies show that more than 70% of older adults prefer quality of life rather than life extension. Yet, 56%-99% of older adults do not have advance directives in place at the time of their ED visit and are at risk of receiving care inconsistent with their goals. Initiating ACP in the ED can be an opportunity to change the trajectory of patient care for older patients.
Common barriers for ACP initiation in the ED include time constraints, limited privacy, and uncertainty in patients’ awareness of their illnesses. A 6-minute motivational interview has been developed specifically for emergency physicians to help them engage their patients in thinking about goals of care. This intervention can motivate patients to hold more time-consuming, sensitive conversations during outpatient visits with their primary care physicians, with whom they typically have longer relationships.
The effects of these interventions are still being tested at this time, along with other studies examining potential benefits of incorporating palliative care in the ED. While many studies on this topic are ongoing, it’s evident that integrating palliative care training into the specialty of emergency medicine will have a significant impact on the quality of care given to our aging population.
George N, Bowman J, Aaronson E, Ouchi K. Past, present, and future of palliative care in emergency medicine in the USA. Acute Med Surg. 2020;7:e497.