The ED -- A Time and Place for Palliative Care

November 2009

By Diana Mahoney
Elsevier Global Medical News

BOSTON -- The integration of palliative care into emergency medicine almost feels like a contradiction, Dr. Tammy E. Quest acknowledged.

"Those of us in emergency medicine are doing everything we can to keep patients from dying, while palliative care regards dying as a normal process to be respected," said Dr. Quest at a meeting titled "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach."

In fact, the tenets of palliative care--the prevention and relief of suffering through the identification, assessment, and treatment of pain and associated physical, psychosocial, and spiritual problems, according to the World Health Organization--are particularly well suited to emergency medicine and should be embraced by emergency physicians, said Dr. Quest.

"We are often on the front line of seeing patients who are, temporally, really at the crux of their crises," she noted. For example, studies have estimated that about 10% of all terminal cancer patients have had an emergency department visit within their last 3 days of life. "We are in a position to help assure that patients such as these who are terminally ill will get the comfort care they and their families need," said Dr. Quest, a professor at Emory University, Atlanta.

Unfortunately, only about 6% of the nation's emergency medicine systems have palliative protocols in place, she noted. In fact, she said, many emergency clinicians still operate under the outdated model, whereby "when a patient presents with a serious illness, we go, go, go, go, go, trying all types of treatments--and only when we've exhausted all of the interventions and they've all failed do we sit down with the patient and family and say, 'I'm sorry, but there's nothing else to do.' "

In contrast, the newer care models value quality over longevity, and are built on a foundation of symptom management, realistic prognosis, and early communication with patients and families to ensure their comfort care needs and goals are being met, said Dr. Quest.

Specifically, palliative care in the ED should include the development of skills in the following 12 core domains extrapolated from the National Guidelines for Quality Palliative Care, which Dr. Quest and her colleagues outlined in a recent report (Ann. Emerg. Med. 2009;54:94-102):

  • Assessment of illness trajectory and decline. "Assigning patients to a [critical] illness trajectory can help guide expectations and communication, and determine the best use of emergency department, hospital, and community palliative care resources," Dr. Quest noted.
  • Basic formulation of prognosis. This helps set the framework for using evidence-based care and avoiding unnecessary interventions.
  • Difficult communication. "Delivering bad news about a patient's prognosis can be difficult, but is necessary in order to set realistic goals," said Dr. Quest.
  • Advance care planning. This includes discussions with patients and families about their desire for and appropriateness of aggressive resuscitative interventions.
  • Familiarity with protocols. Physicians should know protocols regarding the presence of family during resuscitation efforts.
  • Symptom management. Managing patients' pain and nonpain symptoms will improve life quality.
  • Withdrawal or withholding of nonbeneficial treatments. This can lessen the suffering of patients and their families.
  • Management of the imminently dying. This includes the recognition of and respect for natural dying and death and reliance on comfort measures, "which can be difficult for emergency clinicians whose instinctive response is to attempt resuscitation," said Dr. Quest.
  • Knowledge of hospital and community hospice and palliative care systems. This can facilitate appropriate referrals.
  • Awareness of relevant ethical and legal issues.
  • Recognition of spiritual and cultural considerations.
  • Familiarity with the special considerations surrounding the management of a dying child. These include parental preferences about being present during interventions.

Recent certification and training initiatives should play an important role in determining the best way to integrate palliative care into EDs, she said.

One example is the education dissemination project called Education in Pal-liative and End-of-Life Care-Emer-gency Medicine ( Funded by the National Cancer Institute, the project is designed to teach the essential clinical competencies in emergency palliative care, said Dr. Quest, who directs the project.

In addition, the American Board of Emergency Medicine has joined nine other specialty boards in cosponsoring hospice and palliative medicine as an official subspecialty, which means emergency physicians can pursue palliative medicine certification, Dr. Quest noted.


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