Message from the Chair - Palliative Medicine Section Newsletter, March 2013
Mark Rosenberg, DO, MBA, FACEP, FACOEP-D
Wow, we made it. We are now a bona fide section with more than 100 members. Before I get to the activities, I wanted to tell you about the excitement surrounding our new section. It started at our meeting at the Scientific Assembly in Denver. That morning I prepared for a small turn out. I put together a power point and went to the conference room. First, our staff liaison, Marilyn Bromley arrived… then a couple of people wandered in. Soon a few more including Dean Wilkerson, ACEP’s Executive Director; and ACEP President Andy Sama and President-Elect Alex Rosenau. Standing room only for the first meeting!!!!!! The meeting was an overwhelming success. It was scheduled for one hour but after 90 minutes of discussion we still had a full room.
Other good news happened at the ACEP board retreat. Palliative medicine was not only discussed, but ACEP and the Board are embracing palliative medicine as an important part of emergency medicine’s future direction.
As chair of this section I wanted to give an update of the activities for the coming year. The first initiative is to work with the Emergency Medicine Practice Committee on their 2012-2013 Objective 3: “Continue to provide guidance and resources on best practices for palliative and end of life care in the ED.”
We have a group of members that have formed the Palliative Medicine Steering Committee. We had two conference calls in which the working committee decided on three areas to focus on this year. This focus would not only meet the needs of the board and the practice management committee but also provide tools for out section members. The three areas are:
1. Develop a mission statement
2. Develop a Web site in conjunction with existing organizations such as CAPC, IPAL, EPEC and others.
3. Develop a primer on how to start a palliative medicine program in your ED.
Mission statement: The draft mission statement was submitted by Deniece Boothe, DO. It represents the mission and goals of the section for the next couple of years. “As the premier membership organization of emergency medicine, we are dedicated to providing excellent care to patients with serious/life threatening illness. Provision of care to this population requires advanced knowledge and expertise in palliative medicine. In order to achieve this goal we will work on a tool kit that will serve and support the ACEP Board and its members. This goal will be further attained through collaboration with the Center to Advance Palliative Care (CAPC) and Improving Palliative Care in Emergency Medicine (IPAL-EM).”
Web site development and Tool Kit with focus on 4 primary areas:
1. Education:
a. Physicians will obtain tools to recognize the needs of patients and families struggling with serious illness
b. Identify opportunities to improve the care for patients and families with serious illness.
2. Program Development: Incorporate core concepts and practices of palliative care in the field of emergency medicine
3. Public Relations: This will also provide the board with ongoing programs that will make ACEP an advocate and leader in palliative medicine for patients with
serious/life threatening illness
4. Physician Well-being
Education Topics
- Symptom management
- Emergencies
- Communication
- Hospice
- Palliative program development.
- POLST form.
- TOC need
- Organize in house and community resources
Temporizing measures
Time sensitive decision
Prognostication and the ED physician
Understanding disease trajectory
Program Development: Components for ED based palliative care program.
1. Environment of Care
2. Quality Initiatives
3. Education
4. Operational Enhancements
5. Coordination of Hospital Resources
6. Coordination of Community
7. Staffing
- Staffing Enhancements
- Nurse Coordinator
- Social Worker
- Case Manager
8. Patient Satisfaction Extras
9. Extended Home Observation
As we move forward, please encourage your fellow emergency physicians to join our section! If you would like to get more involved or have more information, please do not hesitate to contact me or the secretary of this section, Kate Aberger. Our contact information is found on the home page of our section microsite.
About Dr. Rosenberg: Dr. Rosenberg is Chairman of the Department of Emergency Medicine; Chief, Geriatrics Emergency Medicine; and Chief, Palliative Medicine; at St. Joseph's Healthcare System in Paterson, NJ
Message from the Board Liaison - Palliative Medicine Section Newsletter, March 2013
William Jaquis, MD, FACEP
I am honored to be part of the initial development of the Palliative Medicine Section and to contribute to its first newsletter. I would like to thank all of you who are passionate about the value we can provide to patients, their families and our health care system in turning more of our attention to palliative care. There is currently great interest in ACEP in expanding the knowledge and reach of the members of our College related to palliative medicine. We are challenged frequently by those outside the house of EM to prove our value. The ACEP leadership and Board see this area as another place where our contribution to patient care demonstrates our commitment to value. I look forward to learning more from all of you, and finding the best intersection of emergency care and palliative care.
From the Newsletter Editor - Palliative Medicine Section Newsletter, March 2013
Kate Aberger, MD, FACEP
Welcome all to the Palliative Medicine Section newsletter! My name is Kate Aberger, I practice emergency medicine at St. Joseph's Regional Medical Center in Paterson, New Jersey. I am also core faculty for our stellar emergency medicine residency program. This past year, I refocused my academic efforts on palliative medicine. I qualified for and passed the Hospice and Palliative Medicine boards, and I also participated in a life-altering course offered by Harvard entitled the “Palliative Care Education Program,” which I highly recommend to anyone who wants to broaden and deepen their understanding of palliative medicine.
Emergency medicine and palliative medicine can absolutely coexist, although it will take a shift in culture and mind set. It can start with each of us, when we make that connection with a patient and family that may not “save” them, but will ultimately save us. I would like to ask anyone who has a case or a story that illustrates the use of, or need for palliative medicine in the ED to submit for publication in this newsletter. Please feel free to share frustrations, joys, or experiences that have shaped who you are or who you want to be as a physician caring for those with life limiting illness.
We in the ED have a unique perspective and a unique opportunity to change the way medicine is delivered in this country to patients and families with life limiting illness. Get involved!!
Stay Connected - Palliative Medicine Section Newsletter, March 2013
Randall M Levin, MD, FACEP
A long-time ED physician combats burnout and stays connected to his core values through palliative care. The core attributes of a Palliative Care Physician, authenticity and communication skills, allow us to be more connected to our patients, to be present, and to express our empathy and compassion in a healing manner. This decreases some of the triggers for disconnecting from our inner healing spirit and our reasons for why we entered the field of medicine. We should not only welcome palliative care into our departments and utilize the strengths of a palliative care physician, but more importantly, use them for ourselves to acknowledge our own spirit.
The manual skills, the critical thinking and didactic knowledge base that allow us to do our job should not be mutually exclusive of being connected to our core values and to our patients. A surgeon once said that “the healing power of my soul connects to the needle holder which connects to the needle and is then connected to the patient.” The DISconnect between these is one of the triggers of burnout and early retirement. There is a significant difference between saying that I can do that which stabilizes, treats, or cures versus saying that I can truly to heal. Simon, et al states that “Self-awareness of one’s own reactions towards patients and their relatives is of paramount importance for all professionals in palliative care.” http://www.ipac.org/fileadmin/user_upload/publikation/Simon-Core_attitudes_of_professionals_in_palliative_care_a_aqualitative_study_-_2009.pdf. As healers we can strive for this self-awareness as we care for all patients. Patients are looking to us for this type of interaction and honesty. Studies have shown that proper communication skills increases patient satisfaction and decreases lawsuits. Having a strong sense of therapeutic alliance with their caregiver allows patients to trust, be open to treatment options, and follow medical recommendations. (Holly Prigerson PhD, Dana-Faber Cancer Institute, Dying Better: Lessons Learned from “Coping with Cancer Study” – an Update)
Emergency medicine continues to evolve. Our skill sets and competencies have increased exponentially. But we are only talking about the “science” of medicine. Are we sacrificing our compassion for the mechanical skills of stabilizing and saving lives? What kinds of lives are we saving? Are we “saving” them from death, only to have them suffer in limbo leaving the family to make agonizing choices later on because no one spoke with them? Often we automatically do the mechanics: intubate; plug every orifice with a tube of some sort; send them to the ICU. That leaves someone else deal with the difficult questions about needed vs. futile medical care. We hesitate to get “close to the patient” for risk of feeling emotions. We are trained to maintain a barrier between ourselves and our patients.
These barriers supposedly protect us from “feeling.” Maybe we do not know what to say or are afraid to show our human side out of fear of becoming too transparent and open to our own vulnerability. In teaching, I promote a plexiglass barrier where we can still create our therapeutic alliance and show our empathy and compassion in a safe way to prevent compassion fatigue and allow for appropriate critical decision making vs. an opaque iron shell where nothing comes through and nothing shows. Our patients and their families demand this and deserve nothing less.
One of the physician attributes as outlined by the American Board of Medical Specialties (ABMS) is communication and interpersonal skills. Palliative medicine teaches that communication is one of the most important competencies. There has been ample research and study concerning how physicians lack the confidence in their communication skills for serious illness and more specifically end of life care. Patients and their families report that a low percentage of providers had the conversation with them regarding a serious or terminal illness. (Prigerson Dying Better: Lessons learned from the Coping with Cancer Study seminar, 2010) I personally find that to be the case when patients come into the emergency department with unexpected and frightening symptoms because their provider never discussed the trajectory of their illness. They were not informed of the disease and dying process or about what options they had regarding palliative care. Thus, acute decisions, like intubation, were made more complicated because of the lack of an advanced care plan – leaving families fraught with doubt and guilt.
Let me illustrate with the following case: A frail, elderly female patient was brought in by EMS for chest pain. They found her alone in her apartment without heat. She had no family, was totally alone, afraid, in extreme distress.
It was a busy day in the ED. Our team began to treat the patient with the “knee jerk” approach to an elderly patient with chest pain. We performed all of the algorithmic steps: diagnosed acute myocardial infarction, stabilized with appropriate medication. On top of this, I took some extra time to alleviate her fear. As I was documenting, the patient asked to give me a hug. I said “Thank you, thank you for acknowledging my spirit, I surely will embrace you.”
She clutched my hand, and repeated “thank you, thank you” - I didn’t want to let go. It meant just as much to me, as for her. I accompanied her up to the unit still holding her hand, helped to transfer to her ICU bed and again thanked her. I made sure she was comfortable with her new surroundings, and went back down to the ED. I left that room thinking to myself that this is what medicine is all about, that I was to able to be true to my inner self, to be the doctor that was able to utilize both the science and the art of medicine to be there and to facilitate the “healing” of a fellow human being in an empathetic and compassionate manner.
She died a half of an hour later. You may wonder what did I really do? I did everything that I was trained to do plus had the opportunity to connect with the patient through compassion and empathy – a healing energy for both the patient and the provider. And she died anyway. Was it worth it? Absolutely. My true “role” was not to “cure” but to “heal.” (Palliative concept) She did die, but she died in a warm caring, compassionate environment with others there with her – instead of dying in a cold empty apartment in pain, alone, and afraid. She reached out, we were there.
You may wonder if this was truly a palliative care scenario. Based on the true definition of palliative – to relieve discomfort, to provide care in a compassionate fashion, yes it was. The purpose of sharing this case was to show how when accessing the attributes of palliative care provider to the ED, we are able to benefit from our interaction with our patients in a way that would be “lost” if we only practiced the “science.” This is enough of a reason to encourage emergency physicians and EDs to welcome this into our environment.
When I consider palliative medicine as a subspecialty within emergency medicine, I welcome it for the reason demonstrated above in the case study – to be able to be there for your patient in a humanistic way, to help them along their journey, to give them comfort and what is most important, making a difference for a patient and family beyond your awareness. If we utilize the attributes (empathy, compassion, and giving symptomatic relief) of palliative care physicians with our patients, we will stay connected, we will build self-worth and self-esteem, and we will always be “healing” our patients. We will indeed be addressing the main symptoms of burnout. The workforce of physicians is critically low, and we can’t afford to lose our best.
About Dr. Levin: Dr. Levin practiced emergency medicine for 28 years in both administrative and clinical roles at Aurora West Allis Medical Center Wisconsin. He is an active ACEP member as well as a member of the Wellness Section and the Palliative Medicine Section.
Palliative Care Integration Model in ED: An LIJMC Research Experience - Palliative Medicine Section Newsletter, March 2013
Kei Ouchi, MD
A resident at LIJ shares his experience with palliative medicine in the ED, and how it has shaped his research and personal goals.
Death with Dignity?
I first felt distasteful regret when I admitted Mrs. B for the second time. She was an 88-year-old woman from a nursing home with advanced dementia, sent in for fever. I had admitted her approximately three months ago for the same. According to her last discharge summary, she had septic shock secondary to a urinary tract infection for which she required vasopressor support and a stay in the ICU. She was treated and sent back to the nursing home, only to return today for similar episode. She remained full code.
In the beginning of my training, I accepted these revolving door admissions as how the system works and how patients often deteriorate and die in our country – in the hospital, often alone. I was proven wrong when I witnessed our palliative medicine team meeting with this patient’s daughter to clarify her goals of care based on her mother’s previously stated values. From that conversation, the patient was discharged to an inpatient hospice with comfort care. I realized that there is another way to die in our country – a death that aligns with a patient’s values and can possibly maintain dignity as well.
We as emergency physicians treat multitudes of patients with life-limiting illness such as advanced dementia, cancer, congestive heart failure, COPD every day. Studies show that the majority of Americans visit an ED at least once in the last six months of their lives. Shockingly, approximately fifty percent of decedents come to the ED in the last one month of their lives (1). We spend countless hours learning how to triage and treat many critical patients – perhaps, we need to focus also on recognizing these patients either at, but preferably before the end-of-life (EOL), and triage/treat them appropriately by ensuring to preserve their goals of care.
How We Got Started
Once I realized that most patients with life limiting illness come through ED, I shared my thoughts with my colleagues. I was relieved to hear that many nurses, residents, and attending physicians shared the same frustration but we simply assumed that the system was too complex to change and most responsibilities did not fall to the emergency physicians. Is that really true? In order to study our system to attempt to make a change, I recruited interested staff including nurses, residents, ED and internal medicine attending physicians, case managers, and social workers to form a multi-disciplinary team to attempt to integrate palliative medicine into our ED.
Using the performance improvement model described in the Dartmouth Institute’s Clinical Microsystems http://www.clinicalmicrosystem.org/, our team met routinely to study the current treatment of patients with life limiting illness as well as our ED staff attitudes towards these patients and palliative medicine in general. We found that our ED staff in general lacked understanding of palliative medicine but was open to learning about the services it may provide to our patients. Instead of broadly starting our target population to all at-risk ED populations, we narrowed our target population to advanced dementia patients. We defined these advanced dementia patients by using the validated geriatric scoring system and the Functional Assessment Staging (FAST).
After mapping out the precise flow of advanced dementia patients through our ED, our team employed the model of Palliative Care (PC) integration that allowed us to screen for PC patients and place a PC consult upon admission. The “ED screen for early PC consult” model of PC integration was carefully chosen based on the high volume of our ED and to avoid resistance from ED staff by not creating an additional step in their daily clinical routine. Peer education sessions were conducted to teach the ED staff of different clinical levels, the value of PC in ED settings. Upon completion of the general peer education sessions, multiple PC referral criteria were tested as small tests of change using Plan – Do – Study – Act (PDSA) cycle endorsed by the Clinical Microsystem model of performance improvement. The results of our efforts were tracked using the pre-existing performance improvement database of PC service.
What Is Our Progress?
Since the inception of PDSA cycles in April 2012, the percentage of ED-initiated PC consultations among the overall PC service census was tracked on PC service database. Prior to our intervention, the ED-initiated PC consult consisted of zero percent in the PC service. After April, the number steadily increased to 10 to 12 percent of the PC service monthly.
To further understand the barriers to increasing ED-initiated PC consultations, we performed a pilot study in the ED. Trained research associates used a convenience sampling of advanced dementia patients. These associates interviewed the ED staff regarding their rationale for not placing PC consultation. The results over a one month period revealed that our staff was neglecting to place the majority (approximately 80 percent of advanced dementia patients), and the predominant reasons were “not appropriate,” and “doesn’t change the disposition.” Despite the basic peer education, the importance of PC in vulnerable ED populations was not fully accepted by our staff, and did not significantly change their behavior.
Future Direction?
The secondary outcomes for this pilot study were the clinical outcomes of the advanced dementia patients screened in ED. Within one month, the research associates screened a convenience sampling of 304 patients above age seventy in the ED. Of those, fifty-one patients met the criteria for advanced dementia. Fourteen of the fifty one patients were discharged from the ED and the rest were admitted to the hospital. Of the discharged patients, four patients returned to the ED within one month, of which two resulted in cardiac arrest and ICU stays. Among the admitted patients, only four received ED-initiated PC consultation upon admission. Fourteen received internal medicine (IM)-initiated PC consultations, and the rest of the group did not receive any PC consultation. The length of stay (LOS) was slightly extended for the IM-initiated PC consultation group and no PC consultation group, compared to the ED-initiated PC consultation group.
Three months after the hospital visit, the post-discharge phone interviews were conducted to reveal some insights into caregiver’s perspectives on the care that their loved ones received at the hospital. Two of the four ED-initiated PC consultation group patients had died peacefully at home or hospice facility. Eight out of twelve (Two patients lost to follow up) of the IM-initiated PC consultation group also died, mostly at home or hospice facility. Only one patient died in a hospital. The same proportion of patients in no PC consultation group died as well; however, there were a higher proportion of patients who died in a hospital, and the caregiver satisfaction appeared to be lower compared to the former two groups qualitatively.
We have learned a great deal about the high-risk nature of advanced dementia patients visiting our ED, and some policies for future direction to improve the care for these patients are being discussed. For high-risk patients being discharged from ED, the ED socials workers are being asked to initiate goals of care discussion and offer Physician Order for Life Sustaining Treatment (POLST) forms offered prior to discharge. The results of the pilot study was shared with the ED staff to encourage more early PC involvement for their at risk patients. In addition, the effort is underway to recognize the potential hospice-eligible patients in ED and establish a standardized pathway to a direct hospice disposition.
With all these efforts, our hope is that we are offering the most appropriate health services to the appropriate patients with life-limiting illness, just as we do for all other critical patients in ED. We need to be cognizant of the available disposition options and how to treat their symptoms in ED effectively. At times, we may not be sure exactly how to best treat these patients, but we must continue to strive to be the best physician advocate for them. With this determination and experience in palliative care, I realized that I can be at peace with my professional identity as an emergency physician who advocates for death with dignity when I meet another patient like Mrs. B.
Reference
1. Smith AK, et al Half of Older Americans Seen in Emergency Department In Last Month of Life; Most Admitted To Hospital, And Many Die There.
Health Aff June 2012 31:61277-1285
About Dr. Ouchi: Dr. Ouchi is a PGY-4 combined EM/IM resident at Long Island Jewish Medical Center in New York.
The Need for a Palliative Medicine Service: a Resident’s Case Report - Palliative Medicine Section Newsletter, March 2013
Deniece Boothe, DO
Last night I had two cases that confirmed the need for palliative medicine in the ED. The first: A 59 yo female with history of breast cancer s/p mastectomy and lymph node removal in 2012. The procedure was done in the Philippines and she did not undergo chemotherapy or radiation. Last night she presented to the ED with right leg pain. She stated that she had difficulty ambulating that progressed to severe right leg pain. The x-ray of the right leg showed a pathologic femoral shaft fracture with displacement. We also completed a chest x-ray for pre-op work-up, which was positive for metastasis. I had a detailed discussion with her about her projected hospital course and attempted to admit her to the Orthopedic service. The resident declined the admission and stated that the patient should be admitted to medicine because she would need further management post-op ie, radiation oncology, palliative, etc.
I then attempted admission to the medical service, and the resident stated that the patient could be worked-up as an outpatient and did not require admission. There I was stuck between two services that could easily manage the patient but refused to do so. The patient was finally admitted to Medicine. If we had a palliative unit, the patient would be admitted to the palliative service and all the necessary resources would be provided from there.
The second patient was sent from a nursing home. She had history of breast cancer now with metastasis to liver and bone. She was in moderate respiratory distress, hypotensive, and tachycardic. She had ascites, 2+ pitting edema extending above the knees and she was a full code. I asked her if she understood her prognosis, if she had a discussion with her primary physician about her wishes at the end-of-life and she said no. I was frustrated only because this woman was obviously at the end-of-life and needed critical and emergent intervention. These interventions would probably only prolong her death, and she probably would not wake up again to any meaningful degree. I had the discussion with her as best as I could, but she was firm in her decision. She was intubated, central line placed, NGT had copious coffee ground material, and her lactic acid was 7 among many other abnormal labs. She was packaged and shipped to the ICU. I hope she makes it through to be able to perhaps come to terms with the severity of her illness. The medical system robbed her of that time.
As we embark on this journey, I hope that our efforts as leaders in emergency medicine palliative care will lead to a formal palliative service so that we can best assist these patients.
About Dr. Boothe: Dr. Boothe is a PGY-4 EM resident at St. Joseph Regional Medical Center and is soon to be a first year fellow in Palliative Medicine at Emory University in Atlanta, GA.
Strengthening Communication Skills via CME Activities - Palliative Medicine Section Newsletter, March 2013
Randall M Levin, MD, FACEP
The following CME activity “May We Talk? Having those difficult conversations” regarding serious illness and end-of-life (EOL) care and options focused on communication skills.
The first speaker Mike Bernhagen presented his documentary film (co-produced with Steve Kaldhusdal) Consider the Conversation (www.considertheconversation.com). It is a documentary on the problems with how we now “die” in our society in contrast to how we wish to die. His objective is to open the eyes of society and the medical profession to the broken system that now exists – much of which is due to the lack of communication. Communication is one of the main reasons for discontent, distrust and sense of abandonment, and he expands on how can we improve upon this practice gap.
Studies show that we simply do not communicate these difficult conversations with our patients. There are several reasons for this. Communication and interpersonal relationships competencies are not taught well in our medical schools (only 20% of physicians feel that they have been adequately trained). Another major reason is that doctors fear that by having conversations related to serious and terminal illness, it will take away HOPE and indeed cause harm to the patient. Lucille Marchand, MD addressed this misperception and spoke passionately about how hope does not have to be sacrificed. She described how you can keep HOPE alive, even in the face of a terminal illness. The hope of dying at home, the hope of having family members and love ones surround you at your bedside and the hope that you have the ability to help those around you by healing strained relationships. Not having the conversation does more harm to our patients and their families because we do not allow them time for true healing to take place.
The conversation should be balanced between maintaining the patient’s Hope with the reality of one's disease, its prognosis, treatment options and what to expect with the dying process if terminal, as was appropriately noted by Toby Campbell, MD. In other words, helping the patient and their family to understand and to allow for decision-making – anticipating terminal symptoms takes away from the fear and anxiety of those symptoms. Palliative treatment to help with the symptoms allows the patient to be more in control of their own death.
Communication also involves active listening. This is so important in all types of patient interaction and can not only allow the provider more insight into the patient to help direct care options, but also allows the patient to have the therapeutic alliance with the provider and not feel ignored or abandoned, as was noted by Wisconsin Public Radio (WPR) host Ben Merens. Through storytelling, he was able to describe the steps to being an active listener.
The conference was closed with discussion on the Honoring Choices Wisconsin, an initiative by the Wisconsin Medical Society to address creating and having Advance Care Plans on all patients’ records upon admission to the hospital.
To sum up, communication was the focus of this discussion. Through teaching better communication skills with the focus on active listening and addressing the myth of taking away hope, we will be able to connect more fully with our patients. This will enable us to develop therapeutic alliances and decrease negative perceptions of the care being given. This will also serve to lessen medical mistakes, frustration and medical team dysfunction. Patient satisfaction increases and physician satisfaction increases. This in turn improves the physician self-worth perception and decreases some of the reasons for burnout. This discussion reinforces why we should utilize palliative medicine within our emergency departments.
About Dr. Levin: Dr. Levin practiced emergency medicine for 28 years in both administrative and clinical roles at Aurora West Allis Medical Center Wisconsin. He is an active ACEP member as well as a member of the Wellness Section and the Palliative Medicine Section.