EXECUTIVE SUMMARY
As the benefits of palliative care become more evident in clinical trials, there is growing interest in making such resources available to patients at an earlier stage, such as the ED. However, experts note that emergency staff first must identify available resources and make sure that providers have the primary palliative care skills needed to effectively introduce the topic to appropriate patients and families.
- Research shows that initiating the call for a palliative care consult while the patient is in the ED can deliver quality-of-life benefits even three months later.
- For EDs that lack resources in house, experts advise staff to form partnerships with hospices in the community; some offer sophisticated services and will come to the ED to evaluate patients.
- Emergency staff should establish flexible criteria to identify when palliative care is an appropriate option to introduce to patients and families.
Palliative care receives high marks from patients and families, and the cost of care generally is reduced when they reject intensive care options in favor of measures more focused on comfort and quality of life.
However, in many cases, patients who potentially could benefit from palliative care are presented with this option only after a lengthy stay in an inpatient setting, following days or weeks of suffering with no sign of improvement. For this reason, the subspecialty is experiencing a growing presence in the ED — an earlier stage where many experts believe more benefits could be realized along with heightened patient and family satisfaction.
Although most studies tallying the benefits of palliative care have thus far have involved patients who were introduced to this option as inpatients, investigators in this area have begun to focus more attention on how and when palliative care could be introduced most effectively in the ED, and what happens when appropriate emergency patients receive early access to palliative care consultations.
Ashley Shreves, MD, an emergency physician at Ochsner Medical Center in New Orleans, observes that emergency medicine clinicians and leaders are much more interested in palliative care now than they were when she completed her fellowship training in palliative care in 2009.
“Change happens slowly and it takes a while for the people [with fellowship training in palliative care] to go out and change their departments ... and infiltrate leadership,” she says. “But those things are now happening, and people are talking about it more at the national meetings.”
Identify Palliative Care Resources
The integration of palliative care into the emergency setting has been the focus of much of the research conducted by Corita Grudzen, MD, MSHS, FACEP, the vice chair of research and an associate professor in the Ronald O. Perelman Department of Emergency Medicine at New York University Langone Medical Center. She has found that, particularly for terminally ill patients, palliative care interventions can affect quality of life more positively in line with a patient’s wishes while disrupting a trajectory of intensive measures that drives up costs without making an appreciable difference in outcomes.
However, with limited palliative care resources in much of the country, Grudzen advises emergency medicine leaders who are interested in giving the subspecialty more of a presence in their departments to take stock of what services they offer, both in the hospital and in the community.
“Do you have a palliative care team in your hospital? Most hospitals do,” she says. “A lot of hospitals also have partnerships with outpatient clinics, although some of them are disease-specific.”
For example, Grudzen explains that cancer centers often operate under an integrated model whereby a palliative care provider will work with oncologists. Advanced cardiology clinics or end-stage renal disease centers also may offer this kind of support to patients.
Another point to consider is that even for hospitals with extensive palliative care resources, it can be difficult to arrange for timely consults in the ED.
“Emergency departments are busiest in the evenings, so it really doesn’t help us to have [consults] available from 9 to 5,” Grudzen observes. “We are available 24/7, and most patients come to the ED when the doctor’s office is closed.”
In such cases, it is important to know whether palliative care experts are available after hours or how one can arrange for services most effectively.
Palliative care encompasses a range of multidisciplinary services, from effective symptom management to social supports and expertly driven goals-of-care discussions. Although it is not practical to deliver all of these services within the context of an ED visit, making a palliative care specialist available to patients and providers in the ED can facilitate decision-making so that a plan of care that is in line with the patient’s wishes is initiated.
“Thinking through all these things in advance is really helpful,” Grudzen says. “Know what your services are, find out if they are just inpatient or outpatient, and whether [these resource providers] are receptive to being called and at what times.”
Partner with Hospices
For EDs that don’t have adequate options for palliative care in house, Grudzen suggests finding hospices to partner with in the community.
“I found that these partnerships can be really fruitful,” she says. “Find out if [the hospice] has people who can come to the ED and talk with patients and families, and explain the services available. This can be a great way to get patients out of the hospital and back home.”
Shreves agrees that more EDs should consider partnering with community-based hospices.
“I think people would be surprised by how much — particularly inpatient hospices — can accommodate [their palliative care service needs], so that is one potential solution,” she says.
Of course, not all patients who could benefit from palliative care consultations are candidates for hospice, Shreves notes. However, for those patients who are near the end of life or have a terminal disease, many hospices can deliver good end-of-life symptom management and appropriate social supports, she explains.
In fact, Shreves, who works both as an emergency physician in the ED and as a palliative care physician on the inpatient side, has turned to a community-based hospice when appropriate patients with palliative care needs have presented to the ED.
“I can get a hospice to come in and evaluate people fairly quickly,” she explains. “It is amazing what some of the more sophisticated hospices can and will accommodate, and what they can deliver in terms of patient care,” she says. “A lot of people think that when you go to a hospice it means getting put on a morphine drip and that is it, but most of them are way more sophisticated than that. They provide highly nuanced care, and so I think that is one thing to consider.”
Prioritize the Call for a Consult
Although emergency staff will not always be able to arrange for palliative care consults during a patient’s stay in the ED or even on the same day, Grudzen has found that just initiating the call for a consult makes a difference in terms of quality of life for patients with advanced disease.
“It is one of the few things we can do as emergency physicians where we are actually changing the trajectory of quality of life and care,” she says. “It is a really simple thing we can do, and it takes very little time.”
Grudzen notes that what typically happens when patients with end-stage illnesses present to the ED is that the emergency physician will determine that a patient is too sick to go home and will admit him or her to the hospital.
“Then seven, 10, or 14 days later, someone will say that this patient is dying, let’s call palliative care, so the patient will have this very long hospital stay,” she says. “So, we basically made a trigger so if someone had metastatic cancer and they were ill enough to be coming into the hospital, we would call palliative care the second we made the decision to admit them.”
Looking at this mechanism in a research study, Grudzen found that the early call for a palliative care consult made a difference for patients even three months later.1
“I used to think of emergency medicine practice as kind of just triage for these patients ... where at the end of life I didn’t think we could do much,” she says. “And I have done a complete 180-degree mindset change on that because it is just incredible to see the improvements in a study months later from something that we in emergency medicine can do.”
Shreves adds that while physicians may not benefit financially from enlisting the support of palliative care specialists, they do value these services.
“A lot of physicians have been traumatized by their experiences of providing invasive, aggressive care to people at the end of life,” she says. “Physicians are inspired and motivated to [provide palliative care] because they feel like it is the right thing to do.”
Of course, the key to this approach is knowing when the call for a palliative care consult is appropriate. Grudzen notes that she has seen many different types of triggers. Some hospitals use a checklist while others consider age plus disease or instruct providers to consider palliative care if they think the patient has less than six months to live.
“There are more complex algorithms that are disease specific ... and there are also utilization-based triggers; for instance, a 30-day readmission might be an automatic trigger for palliative care,” she says. “There are many different examples and none of them are perfect, but they are a good starting place.” The most important thing is to have criteria that are flexible, Grudzen adds.
But even with established criteria, many emergency providers are reluctant to introduce palliative care, Grudzen observes.
“There are two problems: The provider will say that the patient is not ready when what the provider is really saying is that he or she is not ready, so there is that,” she says. “Then, I think people just don’t have the skills.”
Although emergency providers are not expected to have tertiary palliative care skills — an advanced skill set one might acquire through fellowship training in palliative care — it is important that they develop primary palliative care skills, such as how to introduce the topic, Grudzen observes. For example, she notes that emergency providers often make the mistake of automatically asking family members if they want everything done for the patient.
“Well, of course they want everything done for a loved done. Who doesn’t want everything done for their loved one or themselves?” she asks.
Instead, Grudzen might ask family members what they understand about a loved one’s prognosis, or she will inquire about what the goals are for the visit.
“If it is obvious that the patient has a very advanced disease, you want to know where the family is at, what their understanding is, and where the patient is at,” she says.
Shreves agrees that a huge part of the palliative care skill set involves learning the advanced communications skills needed to help people understand their treatment options and to globally engage in goals-of-care discussions.
Additionally, while it is not practical to conduct all the psychosocial interventions of palliative care in the ED, it is important for emergency providers to be able to recognize when it makes sense to help patients understand that it may make more sense to focus on their comfort and quality of life rather than to pursue aggressive, invasive treatment. However, Shreves stresses that this is not necessarily an easy call.
“If someone has cancer and they are cachectic ... most people can recognize [that they are near the end of life], but what about if someone has dementia or CHF [congestive heart failure] and COPD and they are frail and elderly?” she asks. “With some diseases, I think it is easy to recognize when the end is near, and for other diseases, it is way more complicated.”
Shreves notes that some emergency physicians have this knowledge base, but it is not an area that residency programs stress generally.
“If you don’t recognize that someone is at a place in their disease where it makes more sense potentially to focus on comfort, you don’t even know when to have that conversation,” Shreves notes. “There is a real variation in practice. Some people will tackle these issues and do it fairly well, and some people will avoid them like the plague because of their own inexperience, discomfort, or lack of training.” (See below: “Tools to Enhance Palliative Care Skills.”)
However, even for emergency providers who have well-developed palliative care skills, time is a universal barrier to engaging in palliative care discussions, Shreves says. However, she notes there are some interesting tradeoffs.
“It is weird when you will make the time to go do an intubation or central line. These things take huge chunks of time, but often if you have a 15-minute goals-of-care discussion, you end up not doing any of those procedures,” Shreves observes. “When you think about it that way, [a goals-of-care discussion] is not always a big investment of time.”
Another barrier that emergency providers must contend with is a lack of information.
“The reality is when you are going to talk to someone about transitioning away from invasive treatment and potentially refocusing on comfort or some in-between pathway, you want to make sure that makes sense, is medically appropriate, and in the patient’s best interest,” Shreves explains. “But that is often a highly complex decision-making process on the physician end, and it requires a lot of data input.”
Consequently, it is not just a matter of taking the time to engage the patient and family in a discussion; it often involves going through reams of medical records to make sure that a shift toward palliative care is a sound option for the patient.
“That is another challenge,” Shreves observes.
REFERENCE
- Grudzen CR, Richardson LD, Johnson PN, et al. Emergency department-initiated palliative care in advanced cancer: A randomized clinical trial. JAMA Oncology 2016;2:591-598.
SOURCES
- Corita Grudzen, MD, MSHS, FACEP, Vice Chair, Research; Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Langone Medical Center, New York. Phone: (212) 263-5550.
- Ashley Shreves, MD, Emergency Physician, Ochsner Medical Center, New Orleans. Phone: (866) 624-7637. Email: [email protected].
Tools to Enhance Palliative Care Skills
Experts note that, ideally, primary palliative care skills should be part of the emergency medicine curriculum, but there are many ways for practicing providers to improve their performance in this area as well. The following resources may be of use to busy clinicians who are interested in enhancing their primary palliative care skill set.
- Vital Talk: http://bit.ly/1pecVtg;
- Education in Palliative and End-of-Life Care: http://bit.ly/2p0LKZa;
- Gemcast. Practical Tips for Providing Palliative Care in the ED: http://bit.ly/2oPqUQB;
- American College of Emergency Physicians. Palliative Medicine Section: http://bit.ly/2pxGOw6;
- EMDocs. Palliative Care in the Emergency Department: A Practical Overview of Why and How: http://bit.ly/2pnaHRc.
Experts note that identifying palliative care options is the first step toward making such services accessible to ED patients.
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