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Palliative Medicine

Palliative Medicine in the Emergency Department

“Palliative care is the medical specialty focused on relief of the pain, symptoms and stress of serious illness. The goal is to reduce suffering and improve quality of life for patients and their families. Palliative care is appropriate at any point in a serious illness and can be provided at the same time as curative treatment. It is not the same as hospice care.”

Source: Center to Advance Palliative Care

As the premier membership organization of emergency medicine, we are dedicated to providing excellent care to patients, including those with serious/life threatening illness. Provision of care to this population requires advanced knowledge and expertise in palliative medicine.

We have provided some tools to help physicians recognize the needs of patients and families struggling with serious illness and to identify opportunities to improve the care for these patients.

Tabs Education
  1. Formal Educational Opportunities in Hospice and Palliative Medicine

    EPEC-EM (Education in Palliative and End-of-Life Care for Emergency Medicine)

    Education in Palliative and End-of-life Care for Emergency Medicine is a two-day conference designed to teach clinical competencies in palliative care to health care professionals working in the emergency department. The conference covers topics specific to ED practice including rapid palliative assessment, disease trajectories and prognosis, care of the hospice patient, chronic and malignant pain management, family-witnessed resuscitation, communication and more. There is also a focus on techniques for teaching the curriculum to other emergency practitioners.

    Hospice and Palliative Medicine Fellowship 

    The American Board of Emergency Medicine is one of 10 sponsoring boards for the Hospice and Palliative Medicine sub specialty. The American Board of Family Medicine houses all of the sponsored programs. The ACGME provides a program listing that can be found using the link below. Additional information about the individual programs can be accessed by clicking on the tab to the right of the individual program.

  2. Additional Education Resources in Palliative Care

    Fast Facts

    Available free from the EPERC: End of Life/Palliative Education Research Center.

    Fast Facts and Concepts provide concise, practical, and evidence-based summaries on key topics.For example Fast Fact # 247- Initiating a Hospice Referral from the Emergency Department.Fast Facts are designed to be quick teaching tools for bedside rounds, as well as self-study. They are published approximately twice a month by EPERC.

  3. Relevant Literature in Palliative Care

    Reference library is available through the CAPC.

    A growing list of reference articles supports the need for the practical aspects of palliative medicine improvement in emergency medicine. These include original research, position statements from national organizations, review articles and more as listed below.This reference library is continually updated as new materials become available.

  4. Palliative Medicine Pocket Companion. International Palliative Medicine Program.

     Link will be added when available.

Program Development

The American Academy of Hospice and Palliative Medicine’s requirements for the successful development of academic palliative medicine programs [position statement]. 2010. Accessed May 14, 2013.

Quality of Care

Quest T, Asplin B, Cairns C, et al. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med. 2011;18(6):e70-e76. doi: 10.1111/j.1553-2712.2011.01088.x.
Weissman D, Meier D, Spragens L. Center to advance Palliative Care consultation service metrics: Consensus recommendations. J Palliat Med. 2008;11: 1294 – 1298. doi: 10.1089/jpm.2008.0178.
Grudzen C, Quest T, Spragens L, et al. Evaluation of ED-Palliative Care Metrics & Quality. 2011. Accessed May 14, 2013.
Palliative Care Services: Solutions for Better Patient Care and Today’s Health Care Delivery Challenges. November 2012. Appendix C: Useful metrics to measure impact and value of hospital palliative care. Accessed May 14, 2013.

Education

Clinical Practice Guidelines for Quality Palliative Care. Second Edition. Accessed February 26, 2013.
Meo N, Hwang U, Morrison RS. Resident perceptions of palliative care training in the emergency department. J Palliat Med. 2011;14:548-555. doi: 10:1089/jpm.2010.0343.

Quest T, Marco C, Derse A. Hospice and palliative medicine:  New sub specialty, new opportunities. Ann Emerg Med.2009;54(1):94-102. doi:10.1016/j.annemergmed.2008.11.019.

ACGME Hospice and Palliative Medicine Core Competencies Version 2.3. Accessed May 14, 2013.

ACGME program requirements for graduate medical education in hospice and palliative medicine. Accessed May 14, 2013.

Operational Enhancements

Lamba S, Nagurka R, Walther S, et al. Emergency-department-initiated palliative care consults:  A descriptive analysis. J Palliat Med. 2012;15:633-636. doi: 10.1089/jpm.2011.0413.

Weissman E, Meier D. Operational features for hospital palliative care programs: Consensus recommendations. J Palliat Med. 2008;11:1189-1194. doi: 10.1089/jpm.2008.0149.
Palliative Care Services: Solutions for Better Patient Care and Today’s Health Care Delivery Challenges. November 2012. Appendix B: Operational features for hospital palliative care programs: Consensus recommendations. Accessed May 14, 2013.

Coordination of Community

Starting and Maintaining a Successful End-of-Life Coalition. 2005. Accessed May 14, 2013

Community-based palliative care: The natural evolution for palliative care delivery in the US.

Next Generation of Palliative Care: Community Models Offer Services Outside the Hospital. California Healthcare Foundation. November 2012

Home-based Palliative Care Services for Under served Populations (Pre/Post Intervention Study)

Effectiveness of a Home-based palliative care program in Kaiser System towards EOL (+ PC vs - PC arm study) - Decreased ED use, more likely to die at home, decreased cost of care, increased satisfaction

Nurse Practitioner and Social Worker-Based Models of Community-based Palliative Care May Not Be Financially Plausible

Community-based Palliative Care. Center to Advance Palliative Care

Cancer network Oncology Journal commentary

Staffing

Assemble Core Planning Team. Accessed May 14, 2013

Staffing a Palliative Care Program. Accessed May 14, 2013

Palliative and End-of-Life Care in the Emergency Department: Guidelines for Nurses

Staffing of Palliative Care Consultation Services in Community Hospitals

Transition of Care

Fast Facts and Concepts #247: Initiating a Hospice Referral from the Emergency Department. Accessed May 14, 2013 

Palliative care and hospice care across the continuum. Accessed May 14, 2013 

Lamba S, Quest T. Hospice care and the emergency department: Rules, regulations, and referrals. Ann Emerg Med. 2011;57:282-290. Doi 10:1016/j.annemergmed.2010.06.569.

Financial

Financing the palliative care program. Accessed May 14, 2013

Billing for palliative care in the ED for EM Providers. Accessed May 14, 2013

Public Relations

FAQs: Palliative Care in the Emergency Department: Enhancing Care in the ED

How does the public define palliative care?
Many believe that palliative care is for patients who are dying. Patients may be reluctant to accept palliative care due to the feeling that the term means “less care”, “abandoning hope” or “hastening death.”

What is palliative care?
Palliative care is the medical specialty focused on symptom management, pain relief and the stress associated with serious illness. The goal is to improve a patient’s quality of life.

Why should palliative care be initiated in the ED?
Patients’ needs should be identified as they are seen in the ED. Appropriate resources can then be deployed to enhance the care of pain and symptom management. Palliative care in the ED as well as linking and leveraging with hospital-based programs that build support internally can improve efficiency, transitions in care, and patient and family experience.

What is the goal of palliative care in the ED?
The goal of palliative care is to begin the process of reducing suffering and ensure the highest quality of life for patients and their families.

The population?
Palliative care is appropriate for patients with serious illness regardless of prognosis at any point in their care. It can be combined with curative therapies like chemotherapy or surgery.

How do patients benefit from palliative care?
An open discussion is held with the patient and family members to determine the goals of care.  Physicians listen to patients and align their treatments with what’s important to them. The patient and family members are assisted with navigating the complex health care system. The patient gains expert individualized care in managing pain and other aggravating symptoms like constipation, insomnia, depression, and fatigue.

What does the palliative care team consist of?
In some facilities the palliative care team consists of some or all of the following: a physician, pastoral services, psychologist/psychiatrist, nurses, social workers, pharmacists, nutritionist. This team works together in an integrated fashion to provide the best care for the patient.

Is palliative care different from hospice care?
Palliative care is appropriate at any stage of serious illness while hospice is palliative care for patients in their last stages of life.

Does the addition of palliative care services increase financial costs to patients?
Palliative care also costs much less than aggressive end-of-life regimens. Patients who receive palliative care services cost hospitals between $1,700 and $5,000 less per admission, according to findings  published in the Archives of Internal Medicine.

How do physicians benefit from practicing palliative care in the ED?
Palliative care means higher patient satisfaction. In the current health care delivery reform environment, palliative care will play an increasingly visible and important role. It will be central in the new wave of integrated Accountable Care Organizations (ACOs) and population-based reimbursement models that are being explored now. Programs that are designed to provide seamless care, from the beginning of an illness to the end, will increasingly rely on the expertise and person-centered approach of palliative care teams.

Additional Resources

ACEP Palliative Care Toolkit- Just-in-time resource to implement palliative care in the emergency department: identification criteria, symptom control, goals of care conversations, disposition planning

 ACEP Palliative Care Informational Flyer-Sample patient referral handout introducing palliative care concepts
Source: David Wang, MD

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