January 29, 2021

Monthly ED Palliative Pulse - January 2021

Clinical Pearl of the Month: Prognostication

An elderly man with metastatic colon cancer presents with pneumonia and respiratory distress. He is obtunded and cannot provide history. His wife states his recent baseline was spending most of his time in a chair when he was not in bed. Prior to this presentation, he was fully oriented and was eating well, but needed considerable assistance with most activities.

Given he is seated/supine most of his day, what do you estimate to be his median life expectancy even prior to this current pneumonia presentation?

His palliative performance status is 50%. In all-comers with solid tumors, this corresponds to a median survival of 71 days.

Emergency physicians’ ability to prognosticate becomes more accurate as patients near the final months of their life. Below are frequently encountered prognostic indicators:


Median Survival

Brain metastases
Better if solitary lesion
Better if primary is melanoma, prostate, breast, or NSCLC

without XRT: 1-3 months
with XRT: 6 months

Recurrent malignant pleural effusion
Better if breast or higher functional status

4-6 weeks without treatment
2-4 months with treatment

Leptomeningeal carcinomatosis

1-4 months

Malignant bowel obstruction
Worse if ovarian or poor functional status

75% die within 3 months (e.g. peritoneal caking)
18% survive > 1yr

Malignant ureteral obstruction
Better if prostate without mets
Worse if low albumin, mets, bilateral hydro

87% dead within 5 months


ED Palliative Program Highlight

Site: Rush University Medical Center, Chicago IL. Academic, 75k ED visits/year. 14 palliative clinicians.

Contact: Carter Neugarten, Director of Palliative Emergency Care, @PalliatED_MD

Clinical Model: Palliative clinician embedded in the ED, 11AM-7PM, Monday-Friday.

Lessons Learned: 1) Less is more: select 2-3 motivated palliative clinicians to be the main presence in the ED to increase recognizability and provide continuity. 2) Partner with ED ancillary staff: identify multi-disciplinary champions, educate and empower ED nursing to place consults. 3) Create an EMR list of all patients seen by palliative. This list can be quickly cross- referenced by patient location to identify high- yield consults. 4) Work with local hospice agencies to streamline direct ED-to-hospice discharges

Communication: 1) Daily presence in the same, high visibility location in ED. 2) Use secure chat within EMR. 3) Add banner to the trackboard with dedicated ED-palliative consult phone/pager number.

Funding/billing: 100% Palliative care funded, consider billing for advanced care planning to optimize RVU. Utilize outpatient billing codes unless patient is admitted.

Next Steps: 1) Survey clinicians to assess the program. 2) Analyze outcomes including hospital length of stay, cost and advanced care planning rates between patients who received ED-initiated palliative care, standard palliative care, or the current standard of care.


Research Article of the Month

Emergency Department Staff Priorities for Improving Palliative Care Provision for Older People: A Qualitative Study (Wright et al. 2018) https://pubmed.ncbi.nlm.nih.gov/28429643

During interviews with EM clinicians four challenges in EM palliative care were identified as priorities: time constraints; communication and information; systems and processes; and understanding of palliative care. Future research and quality improvement projects should aim to help clinicians overcome these barriers.



Subcommittees host recurring workgroup calls. Reach out to Mari Houlihan if interested to join.

Look out for upcoming interorganizational EM-palliative webinar in March.

AAHPM assembly is virtual this year, so our annual EM SIG dinner is postponed until 2022. Come hungry next year!