Palliative Care in the ED: The Bullet Points

September 11th, 2025

Palliative care focuses on improving the quality of life by managing symptoms for patients with serious illnesses at any stage, while hospice care is reserved for those in the final six months of life after curative treatments are stopped. Emergency physicians often are the first to identify critically ill or dying patients and are in a unique position to initiate palliative interventions and guide goals-of-care discussions.

Key Concepts

• When to Consult Palliative Care:
  Indications include serious illness plus factors like recent hospitalizations, uncontrolled symptoms, functional decline, caregiver distress, incurable cancer, or advanced dementia.

• Three Key Illness Trajectories Benefiting from Palliative Care:

  1. Frailty with gradual decline

  2. Terminal illness with rapid deterioration

  3. Organ failure with episodic decompensations

Goals of Care and Code Status Conversations

Emergency physicians must initiate goals-of-care conversations by:

• Understanding patient/family knowledge

• Explaining prognosis in simple terms

• Discussing preferences for life-sustaining treatments (e.g., cardiopulmonary resuscitation [CPR])

• Aligning treatment plans with values and desired outcomes

Advance directives and physician orders for life-sustaining treatment forms should guide care preferences. Misconceptions about CPR’s success should be clarified, especially in elderly, frail, or terminally ill patients.

Symptom Management:

• Dyspnea:
  Treated with opioids as first-line therapy. Benzodiazepines may be used adjunctively for anxiety-related dyspnea. Supplemental oxygen helps only if the patient is hypoxic.

• Pain:
  Adjust existing outpatient regimens using morphine milliequivalents. Use immediate-release agents and titrate based on pain severity.

• Nausea/Vomiting:
  Treat based on etiology (e.g., medications, malignancy, infection). Options include haloperidol, metoclopramide, ondansetron, dexamethasone, and octreotide.

• Constipation:
  Managed with stimulant and surface laxatives; escalate to osmotic agents or methylnaltrexone if opioid-induced and refractory.

End-of-Life Care in the Emergency Department

Comfort-focused treatment includes:

• Regular dosing of opioids, benzodiazepines, and antipsychotics for pain and agitation

• Managing secretions with antimuscarinic agents

• Avoiding unnecessary interventions (e.g., hydration, oxygen in actively dying patients)

• Supporting families through clear communication, spiritual care, and bereavement resources

Palliative sedation may be used for refractory suffering but requires specialist input and a clear ethical framework (doctrine of double effect).

Implementation and System-Level Impact

• ED-based palliative pathways and consultation services reduce intensive care unit admissions, hospital length of stay, and healthcare costs, while improving patient/family satisfaction.

• Early emergency department involvement enables timely transitions to hospice and better alignment with patient goals.

Conclusion

Emergency physicians are instrumental in initiating palliative care, facilitating transitions to comfort care, and ensuring a dignified death. Proactive symptom management, honest communication, and coordinated care can dramatically improve the experience of seriously ill patients and their families.

For more information about palliative care in the emergency department, click here.