Beyond Code Status: Palliative Care Begins in the Emergency Department




Palliative Care Is Increasingly Relevant to the Scope of Emergency Medicine


The aging US population is increasingly dying from chronic rather than acute illnesses. By 2030, 1 of every 5 Americans will be older than 65 years. Advances in management of acute illnesses have helped more patients now live long enough to develop end-stage organ disease, cancer, and dementia. With increasingly complex medical needs, these patients present to their emergency department (ED) with challenging complaints such as functional loss, bounce-back visits for uncontrolled symptoms, and caregiver fatigue. Moreover, these visits point to a gradual decline that is often missed as a result of the usual focus on diagnosis and disposition. Patients may present their needs through subtle commentary ( Table 1 ) that may be readily overlooked as subacute or social issues. However, although these concerns do not appear immediately actionable, early palliative intervention directly affects patients’ quality of life and downstream use of the health care system. Emergency physicians encounter but may not recognize palliative care–eligible patients far earlier than their terminal admission.



Table 1

How palliative care needs may present in the ED.




























Palliative Care Domains How Patients May Voice Their Needs Benefit to Early Identification
Goals of care “Mom never mentioned her wishes…. We want everything done.” Early patient engagement to create a care plan that honors their goals and values before presenting to the ED in extremis
Symptom control (eg, pain, nausea, dyspnea, delirium) “I’m afraid to eat because of the constipation.” Achieving adequate outpatient symptom control to obviate ED revisits and admissions
Functional status “You said this is not life threatening, but I can’t live like this at home.” Early preparation and resource mobilization to anticipate transitions to higher levels of care (eg, caregivers, facilities)
Psychosocial support (eg, caregiver fatigue, faith crises) “I’ve been spending all day with Dad, trying to manage my job and the kids.” Providing longitudinal support to patient, family, and caregivers through emotional, spiritual, and cultural channels
Hospice “No way. We’re not giving up yet.” Demystifying and destigmatizing hospice; early use not necessarily incompatible with some treatment plans




Palliative Care Starts Well Before the End of Life


Despite increasing interest, there remains significant heterogeneity in emergency provider understanding of what is meant by the phrase “palliative care.” Similarly, 90% of Americans have little to no knowledge of palliative care, but when read a simple definition, they would want early palliative care for themselves and their loved ones. Palliative care comprises an interdisciplinary team to provide relief to patients and their families from the symptoms and stress of incurable illnesses throughout the entire disease course. Although hospice and comfort care are subcomponents, palliative care adds significant value well before the final days of life. The best results are enjoyed when palliative care begins serving patients at their initial diagnosis of life-limiting illness ( Figure 1 ), continuing along with their treatments from other specialists and taking on a greater role as their disease progresses. Palliative care teams preemptively address advanced care planning, caregiver needs (eg, housing, resources), streamlined communication between disparate provider teams, psychosocial support, and introducing hospice at the earliest opportunity to benefit. Through these channels, they provide an extra layer of support to ensure that the continuum of care is congruent with the patient’s life goals. Effective palliative care is a parallel process, not a handoff.




Figure 1


Reconceptualizing palliative care as a continuum of support.




Palliative Care Starts Well Before the End of Life


Despite increasing interest, there remains significant heterogeneity in emergency provider understanding of what is meant by the phrase “palliative care.” Similarly, 90% of Americans have little to no knowledge of palliative care, but when read a simple definition, they would want early palliative care for themselves and their loved ones. Palliative care comprises an interdisciplinary team to provide relief to patients and their families from the symptoms and stress of incurable illnesses throughout the entire disease course. Although hospice and comfort care are subcomponents, palliative care adds significant value well before the final days of life. The best results are enjoyed when palliative care begins serving patients at their initial diagnosis of life-limiting illness ( Figure 1 ), continuing along with their treatments from other specialists and taking on a greater role as their disease progresses. Palliative care teams preemptively address advanced care planning, caregiver needs (eg, housing, resources), streamlined communication between disparate provider teams, psychosocial support, and introducing hospice at the earliest opportunity to benefit. Through these channels, they provide an extra layer of support to ensure that the continuum of care is congruent with the patient’s life goals. Effective palliative care is a parallel process, not a handoff.




Figure 1


Reconceptualizing palliative care as a continuum of support.




Palliative Care Is a Win for Emergency Medicine at a Systems Level


With the Patient Protection and Affordable Care Act, health care systems are searching for innovation to curb spending without compromising quality of care. Recognizing the stewarding role that emergency medicine plays in health care use, in 2013 the American College of Emergency Physicians (ACEP) prioritized earlier access to palliative care as one of its top 5 measures in the Choosing Wisely campaign to reduce undesired and unnecessary medical treatments.


Early palliative care is a win-win for patients and health care systems. EDs are an opportune entry point into the palliative care continuum. During the last 5 years, a large body of research has shown that early integration into palliative care reduces ED visits and hospitalizations by up to 50%. This has been corroborated across community, academic, and county practice settings, as well as in diverse disease populations. Even for admitted patients, initiating a palliative care consultation directly from the ED (versus later as an inpatient) shortens length of stay by an average of 4 days, resulting in fewer inhospital deaths while significantly increasing quality of life without reducing overall survival. A 2014 meta-analysis estimated that palliative care consultation reduced hospital inpatient costs by 10% to 30%.


These financial implications are affecting downstream incentives for emergency physicians. In a shifting reimbursement landscape, hospitals are keen to minimize 30-day readmissions because these become unreimbursed care in the transition to bundled payment models. Many hospital budgets operate within a 2% to 4% profitability margin, and Medicare readmission penalties may reduce revenues by 3%. Given this slim buffer, there will be increasing scrutiny and effort on diverting readmissions. By proactively connecting eligible patients with early palliative care and thereby reducing ED revisits and hospital readmissions, emergency physicians continue to project their value in the health care system while enabling patients to receive treatment congruent with their goals of care.




Palliative Care Education Is Needed for All Emergency Physicians Regardless of Experience


The anticipated gap between the need for and supply of palliative care providers is rapidly widening. There may never be a sufficient volume of fellowship-trained palliative physicians to deliver palliative care to all comers. Fortunately, most patients do not necessarily require skilled “secondary palliative care” around complex ethical issues and symptom management. As highlighted in the 2015 Institute of Medicine report, most patients’ palliative needs can and must be addressed by medicine’s frontline providers. Emergency physicians must now develop “primary palliative care” expertise unique to their practice climate.


Whenever a new domain of practice such as palliative care is introduced into emergency medicine, there are no preexisting content experts. Therefore, increasing years of clinical experience do not necessarily translate into advanced knowledge and skills. Even in teaching institutions, the traditional model of knowledge transmission from attending physician to resident may be insufficient because both are learning groundbreaking developments in tandem. A recent academic center survey demonstrated that a significant majority of attending physicians and residents believe palliative care to be an essential core competence for their practice and desire additional training. However, attending physicians do not report any greater ability or comfort with managing palliative care patients in the ED than senior residents. Although a majority of emergency medicine training programs teach and identify palliative care as a core competency, they also report that the absence of experienced faculty is the most significant educational barrier.


Both emergency providers and out-of-hospital personnel would also benefit from greater education on interpreting the myriad of advance directives, including state-specific Physician/Medical Orders for Life Sustaining Treatment (POLST/MOLST) forms. These signed physician orders follow patients throughout care settings, from their places of residence to nursing facilities to the hospital. They are most useful in the out-of-hospital setting and on initial arrival to the ED if no further collateral information is immediately obtainable. Although these have helped emergency providers better adhere to patient wishes, many are confused by how to interpret seemingly conflicting forms that state both “do not resuscitate” (applies when a patient is found without a pulse) in one section and “full treatment” (applies when a patient still has a pulse) in another. In this example, a patient in respiratory extremis from pneumonia and septic shock may still warrant intubation and vasopressor support, but should receive neither if arriving pulseless.


On the other end of the spectrum, it is equally important to distinguish that “do-not-resuscitate” is not equivalent to comfort care. Health care team members often erroneously conflate “do not resuscitate” with “do not treat,” which leads to worse clinical outcomes. Although patients with do-not-resuscitate orders decline invasive interventions, they may still desire noninvasive treatments for reversible insults (eg, early antibiotics and fluid resuscitation in sepsis) if this permits them to return to an acceptable quality of life. In these time-sensitive situations, it is imperative to diligently clarify patients’ goals of care beyond just code status: their functional baseline, what would constitute a meaningful recovery, and how today’s presenting illness fits into the natural history of their disease.


Developing mastery of these new palliative care core competencies is an emerging and timely challenge for all emergency physicians irrespective of clinical experience. It would be advantageous for training programs to be flexible in recognizing when learning would be better achieved through a collaborative approach rather than vertical hierarchies. A unified mission may ease comfort during this transition and encourage knowledge sharing among all stakeholders. To this end, ACEP is developing a skills guide for learners of all levels to increase palliative care competence relevant to their daily practice of emergency medicine.




Implementing Palliative Care in the ED


Given that many palliative care–eligible patients present to the ED, emergency physicians are positioned to become leaders in advancing this standard of care. The ED has a unique opportunity to serve as a hub for unmet palliative care needs ( Figure 2 ). Some elements of high-quality ED palliative care will require augmenting emergency physician skills in delivering primary palliative care, such as expanding current approaches to symptom palliation and refining goals-of-care conversations. Other elements will involve leveraging a broader set of resources as they become available, such as other ED team members, as well as accessing palliative care teams and nontraditional dispositions. Fortunately, frameworks and protocols are under development to mitigate additional workload and assist emergency physicians in increasing the effectiveness of their time already spent on these challenging issues.




Figure 2


EDs can serve as a palliative care hub.


Early Referral to Palliative Services


Ninety percent of large US hospitals (>100 beds) and two thirds of those with 50 beds or more now have palliative care programs. Emergency physicians often glimpse patients’ decline well before their primary providers and therefore may be the first to consider palliative care. For patients requiring inpatient evaluation, consider placing or recommending a palliative care consult with the admitting team. Similarly, for patients being discharged, consider placing an outpatient referral request as an opportune early entry point into the palliative care continuum.


Identifying these patients well in advance of their terminal admission is a critical challenge. Although comprehensive screening tools are being developed and validated, perhaps the single easiest and most predictive tool remains the question, “Would I be surprised if this patient dies in the next 12 months?” To evaluate this trigger, a recent prospective cohort study of general practitioners found that an answer of “not surprised” yielded a positive predictive value of 84% and negative predictive value of 69%, with odds ratio 11.5 (95% confidence interval 5.83 to 23.28) and hazard ratio 6.99 (95% confidence interval 3.75 to 13.03) for death at 1 year. Although not yet validated in an ED context, this simple question has the potential to be actionable in time-limited settings. There is need for further research to better characterize and access the palliative care–eligible population in EDs.


Primary Palliation of Symptoms


Residents and attending physicians have identified controlling refractory symptoms and managing imminently dying patients as primary gaps in expertise. In 2014, ACEP developed and released a Palliative Care Toolkit to provide a timely resource to emergency physicians. It can be accessed publicly on the ACEP palliative care section Web site. The symptom management component of the toolkit is shown in Table 2 . An important component is the judicious use of opioids in mitigating dyspnea. Recent literature dispels the assertion that opioid use hastens death, thus rendering moot the “principle of double effect” that some measure of harm is acceptable in achieving an intended greater good. Opioid use titrated to comfortable respiratory rates does not significantly alter PCO 2 , PO 2 , or overall survival but does significantly increase comfort at the end of life.


May 2, 2017 | Posted by in EMERGENCY MEDICINE | Comments Off on Beyond Code Status: Palliative Care Begins in the Emergency Department
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