Editor's Forum, Palliative Care

Quality of Life(Saving) Care in the ED

EM has come a long way from its humble beginnings as a specialty practiced in hospital basements with scarce resources and minimum hospital support. As emergency physicians fought for our place in the house of medicine, the expectations for the care we deliver in the ED grew exponentially. In the modern era, emergency physicians maintain an ever-increasing scope of practice that often extends far beyond the initial resuscitation and diagnosis of life-threatening pathology.

With current trends toward increased boarding times in EDs across the country, emergency care has become a complex and multi-stage event that extends hours past the initial evaluation.

At its most basic definition, palliative care is the term given to describe the medical care provided for patients with serious illnesses. In a typical shift, this definition might apply to any number of patients receiving care in our crowded EDs. While the word palliative immediately calls to mind the idea of a patient in extremis, this represents just one of the many instances in which palliative care interventions have been shown to improve the quality of life for patients.1

The Model of the Clinical Practice of Emergency Medicine (EM Model) is produced by the American Board of Emergency Medicine (ABEM) and serves as a content blueprint for ABEM examinations. The EM Model clearly identifies end-of-life and palliative care (20.4.4.1) as a core competency of the practice of emergency medicine. Advance directives, coordination with hospice services, and organ donation are all specific topics that emergency physicians are expected to understand and apply while caring for patients.

But how can these individuals be identified quickly and efficiently in the fast-paced world of EM?

The ACEP Palliative Medicine section has created a toolkit2 that can be used to rapidly screen patients for potential benefit from palliative care resources. Designed to function as a quick check list, the criteria include diagnosis of a non-survivable illness and any one of 5 additional elements. These can be summarized to provider-estimated life expectancy of less than 12 months (or anticipated death prior to adulthood, for children), multiple ED visits for the same condition in the past several months, uncontrolled symptoms (eg pain, dyspnea), functional decline, and complex care requiring increasing support. While this tool is intended for use in patients who already carry the diagnosis of a non-survivable illness, it also serves as a helpful reminder to identify high-risk features of other critically ill patients who may benefit from palliative care services.

During EM training, there is ample opportunity to develop skill in palliative care. While routine EM practice provides significant experience, there are multiple ways to hone palliative care skills outside of the ED. During ICU blocks, interaction and collaboration with palliative care specialists is a common occurrence and can provide an excellent complement to the wealth of knowledge acquired during these rotations. In addition, many residency programs offer the ability to work directly with hospice and palliative medicine services during elective months. Fellowship in hospice and palliative medicine is increasing in popularity among EM graduates, and many residency programs have recruited emergency physicians with this background for the exact purpose of emphasizing this importance skill set on shift.

For EM residents interested in pursuing fellowship training in palliative care and hospice medicine, ABEM offers subspecialty certification to graduates of ACGME-accredited Hospice and Palliative Medicine fellowships. While there are currently 10 specialties including EM that offer subspecialty training in this discipline, the American Board of Internal Medicine (ABIM) creates the subspecialty certification exam that is currently held every 2 years.3

At the interface of the initial resuscitation and ultimate disposition of critically ill patients in the ED lies a dynamic period during which emergency physicians are the sole providers communicating life-changing diagnoses and prognoses to patients and their loved ones. It is during this time that this essential skill set of our craft can provide the key resources, support, and comfort needed during devastating disease processes. Just as we strive to perfect the art and science of resuscitation, so too should we strive to provide high-quality palliative care.


References

1. Stephens CE, Hunt LJ, Bui N, Halifax E, Ritchie CS, Lee SJ. Palliative Care Eligibility, Symptom Burden, and Quality-of-Life Ratings in Nursing Home Residents. JAMA Intern Med. 2018;178(1):141–142.
2. ACEP Palliative Medicine Section. Palliative Care Toolkit. Accessed September 2018.
3. American Board of Emergency Medicine. Hospice and Palliative Medicine Certification Exam. Accessed September 2018.

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