The emergency department (ED) cares for people with conditions all along the spectrum of illness and injury: Those with chronic, progressive illness and those with acute illness; those with and those without good support systems. Although the primary role of the ED is to care for the critically ill and injured, many patients and families with nonemergency, urgent needs are nonetheless in crisis. The ED serves as a vital access point for medical care for people who are suffering, and it is a way station for those in need of crisis intervention.
Understanding the Emergency Department Model
Perspectives for Non–Emergency Department Providers
Evaluate and treat, admit or discharge —this is the mantra of the ED clinician. Patients with palliative care needs present to the ED for an array of reasons, often crisis driven; their symptoms or pain may have escalated or perhaps the caregiver has panicked. Exceptional symptom management and procedural skills are critical in the ED. A fundamental understanding of how most EDs operate and knowledge of common barriers to palliative care are important first considerations.
Triage
After a visit to the ED, a clinician or relative may reasonably ask: Why was my patient with cancer and uncontrolled pain in the waiting room of the ED for hours before being seen? How quickly a patient’s needs are met is one factor in the minimization of suffering. EDs serve a unique role in our society as a 24-hour safety net for the suffering, the underserved, and those with limited social or economic resources to access primary care. This is true of palliative care as well as other types of care. That said, ED overcrowding is well described across the world and is best documented in the United States, Britain, Canada, and Australia. Overcrowding results in long patient waits at a time of crisis for them.
When patients arrive in the ED, they undergo triage. Triage means “to sort.” The general purpose of a triage system is to classify patient presentations in a way that determines the potential for deterioration and the urgency with which evaluation by a physician or nurse is needed. This is typically done using a combination of factors that includes a patient’s appearance, vitals signs, and underlying conditions that present a possibility of threat to life. Under established emergency triage systems, patients who present with mild to moderate exacerbations of chronic illness are triaged to lower priority and therefore often have longer ED waits. Common triage systems generally assign patients who have no immediate threat to the respiratory or cardiac system to a semiurgent or nonurgent level. This results in potentially very long waiting room times and can cause discomfort to the patient and family. For instance, under the Canadian Triage and Acuity Scale, a patient with moderate to severe pain (4 to 7 on a scale of 0 to 10) would have a time-to-physician wait of more than 1 hour, and a patient with constipation would be triaged at the lowest triage priority level (level 5) with an “ideal” wait time of up to 2 hours before even being assessed by a nurse.
Health care professionals who interact with the ED should be aware of the resource constraints and priorities of the emergency setting and should not confuse this with a lack of caring by emergency personnel. Because the focus is on rapid identification of life threats, stabilization of vital signs, and airway management, relief of physical symptoms distress may sometimes take a lower priority than is desirable. Psychosocial aspects of a patient’s needs may also not be adequately explored and may even be detailed only if they relate to the triage decision.
Environmental and Systems Barriers
The setting of the ED typically lacks both privacy and the extended spiritual and psychosocial resources that would be more readily available to patients and families in the inpatient or outpatient setting. When available, these resources are typically crisis oriented. The significant time pressure, general lack of privacy and seating, and high level of noise and distractions make the ED environment especially challenging. In the emergency setting, a practitioner must often forego his or her vision of optimal palliative care to meet the patient and family in the midst of crisis. Because of the never-ending stream of patients, the essential focus is on disposition: Where does this patient need to go next? Emergency providers are in search of critical pieces of history, physical findings, laboratory tests, or radiography that determine the disposition—admit, discharge, or transfer.
How to Assist Emergency Personnel
Emergency physicians and nurses are required to make pressing decisions in an environment of information deficits. Time constraints allow for very little time per patient, yet the doctor and nurses are expected to decide the vital next steps for the patient. Actively calling the ED staff, responding to them rapidly (by phone or in person), and letting the ED providers know what to expect are extraordinarily useful. Referring clinicians can be especially helpful if they are familiar with and explicitly communicate a patient’s previously stated goals of care or treatments preferences because this knowledge can aid in targeting the correct disposition.
Perspectives for Emergency Medicine Clinicians
Bedside Rapid Trust Building
In view of the dynamics and workings of an ED, it is important to build trust rapidly, but this can be a particularly difficult task. ED patients with a variety of diagnoses have identified several factors as important for building trust, specifically the following:
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Being treated as an individual
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Not having reason to see the clinician as someone who is too busy to see them
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Having reason to expect clinicians’ compassion at the bedside
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Clinician sensitivity and concern
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Having reason to expect clinician honesty
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Having open discussion about treatment options
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Having confidence that the patient’s interests come first.
Surprisingly, factors rated as less important for trust building included the patient’s perception of the clinician’s competence, the clinician’s expression of hopefulness or empathy, and the clinician’s ability to use laymen’s terms. To foster this trust and to honor these considerations, special trust building skills are necessary. Some key skills are suggested in Table 36-1 .
| Emergency Department Provider Should: | Suggestions/Script |
|---|---|
| Avoid seeming too busy | Lean over the gurney and maintain eye contact when no chair is available. |
| Use nonrushed body language | Hold the patient’s hand during the initial contact/discussion. |
| Be compassionate at the bedside | Maintain eye contact. |
| Use affirmative phrases that acknowledge the patient is human, not a number | “With so many distractions in the emergency department, I know it is difficult to discuss things … but you have my full attention now.” |
| “This can be a difficult setting to get your needs met, but we will do our best.” | |
| “If I am called away suddenly, it is not because your problem is not important, and I will be back as soon as I can.” | |
| Show sensitivity and concern | “I know it is hard to speak with a perfect stranger regarding these issues, but it is how I can help you best.” |
| Be honest | “I want to be honest with you regarding how long things will take …” |
| “I want to be honest with you regarding what I see happening, even if it is difficult to talk about.” | |
| Use open discussion regarding treatment options | “Based on what I know medically, this is what the options are … this is what I would recommend.” |
| Keep the patients’ interests beyond all others | “I am most concerned with what is right for you.” |
Revealing the True Effectiveness of Cardiopulmonary Resuscitation
Patients, surrogates, and providers alike may be misinformed about the effect of cardiopulmonary resuscitation (CPR) on a chronic medical condition. Resuscitations should not be described in gruesome or gory terms, but families should be aware of the facts of CPR, including those that pertain to futility when this is relevant. Perhaps influenced by what can be seen on television, the overwhelming majority of laypersons feel that CPR is effective. Because 75% of patients on television survive initial resuscitation and 67% survive until discharge, this view is understandable. In spite of the stress and pressure that exist in the ED and in discussions of CPR, when providers talk to patients and families, they should acknowledge the difficulty of talking about the outcomes of CPR and not avoid the conversation. Studies have shown that patients in the ED are willing to hear news of a life-threatening illness.
Core Palliative Care Skills in the Emergency Setting
Core skills in the ED setting include global prognostication, recognition of sentinel ED presentations, noninvasive management of an impending cardiorespiratory arrest, noninvasive management of respiratory failure, management of severe uncontrolled pain, family-witnessed resuscitation, and death disclosure. All these skills require excellent, rapid communication and trust building.
“Big Picture” Prognostication
Consider the case of an 85-year-old man with stage IV lung cancer who presents in respiratory failure with no advance care plan regarding resuscitation. How should the emergency provider advise the patient and family regarding CPR without knowing the details of the patient’s history and treatments?
Many patients and families with palliative care needs have limited understanding of their prognosis and do not have advance care plans. Because of the information deficit, the emergency provider will not be able to easily estimate life expectancy but can more accurately define “the big picture.” For example, the typical patient with cancer who is on a dying trajectory and who presents with a new urinary tract infection may recover from the infection but will still have terminal cancer after the infection is treated. If this information is communicated directly to patients and families, they may elect to treat the symptoms associated with the infection but not the infection itself, and may regard the infection as a natural opportunity to die. A corresponding decision may be made to forgo resuscitation attempts. If the patient and family still need to fully realize that the patient will still have cancer even if resuscitation is successful, this is an important “big picture” communication that will allow an optimal decision for all concerned.
Important steps in rapid prognostication include the following:
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Define the chronic, progressive, life-limiting illness.
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Define the “new event.”
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Communicate the global prognosis—the “big picture”: Treatment of the new event will not reverse the chronic illness.
Sentinel Emergency Department Presentations That Indicate the Onset of Active Dying
Some sentinel presentations suggest terminal decline in a patient with chronic, progressive illness and signal that an important decision point may have arrived. Sentinel presentations include:
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The inability to eat or drink
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Generalized weakness
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A new illness or injury that would require major intervention (e.g., acute myocardial infarction, fracture, intracranial hemorrhage)
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Last hours of living
Such presentations should alert the ED clinician to the potential need for hospice, inpatient palliative care service, or preparation for a death in the ED. Patients often present with a new constellation of symptoms that are related to the natural progression of the underlying disease.
The progressive inability to eat or drink and generalized weakness may signal progression of illness with or without an acute underlying event. The inability to take nutrition or reaching a point of critical weakness is often a pivotal point for families and caregivers. The ED response is typically to initiate artificial hydration and search for an underlying cause. What should be considered at that juncture is whether the search for a precipitating diagnosis is helpful in view of the relevant risks, benefits, and alternatives. Some patients and families are not willing to undergo invasive testing or painful procedures to give a name to, or even to attempt to reverse the course of, a new illness. Although an artificial feeding device may be appropriate in some cases of inability to eat or drink, patients and proxy decision makers should be empowered to decline these types of interventions if they wish to do so.
Patients who present with progressive, life-threatening, terminal illness may present with a clinical constellation that could potentially be treated with acute surgical or medical interventions (e.g., an orthopedic or neurosurgical operation). Clarification of the goals of care coupled with the global prognosis are key elements to discuss with the patient and family to guide ED clinical decision making. The ED provider should formulate a “big picture” prognosis (perhaps in conjunction with the specialist), assess the range of goals for the patient, followed by recommendations for interventions or therapies.
Patients who present within the last hours of living special attention. These signs include: includes marked weakness, inability to swallow, loss of the ability to close the eyes, skin mottling, tachycardia, and neurologic dysfunction. Signs of imminent death deserve special attention. For these patients, if not yet clarified, the issues of life-sustaining therapies in the event of natural death, such as CPR, must be addressed. A proactive assessment of goals of care may avoid unwanted and futile resuscitations. When cardiovascular collapse can be anticipated within hours or days, proactive discussions should be attempted if relevant plans and physician orders regarding interventions at the end of life are not already in place. In patients with cancer, for example, studies have shown the survival to hospital rate of CPR to be 0% when clinicians anticipate that a patient with cancer may experience cardiopulmonary arrest for which the clinical course could not be interrupted by life sustaining therapies. Even though the provision of nonbeneficial interventions is upsetting to emergency providers, studies show that providers will perform cardiopulmonary support even when they are sure it will not change the outcome because they fear litigation, anger, and criticism by the patient or family. Ultimately, this is generally not helpful for providers, patients, or families.
Noninvasive Management of Severe Respiratory Failure
Conversations about resuscitation with patients at high risk for pulmonary decompensation, such as those with chronic obstructive pulmonary disease and congestive heart failure, often revolve around invasive or noninvasive supportive airway management. Emergency physicians should ask patients with chronic obstructive pulmonary disease or congestive heart failure about their desires for supportive ventilatory therapies such as endotracheal intubation and noninvasive (NIV) airway management. NIV is an increasingly common modality in the emergency setting as a safe and effective rescue therapy that may serve as a bridge. NIV may represent an intermediate step to endotracheal intubation, but it may also help to avoid endotracheal intubation altogether when time is needed to try therapies that may need several hours or days to become effective (e.g., antibiotics, bronchodilators). Additionally, NIV can buy time when critical conversations need to be held. When the issue of resuscitation has never been discussed or no conclusion has been reached, NIV can give the provider and patient or surrogates time to stabilize the patient, gather surrogates, and discuss the potential risks, benefits, and recommendations of more invasive airway management and even cardiopulmonary resuscitation in the event of cardiac arrest. NIV can also temporarily relieve dyspnea during the period when other palliative therapies for breathlessness or terminal dyspnea are being initiated. Candidates for NIV should be hemodynamically stable, conscious, alert, and cooperative, even though fatigued (increased respiratory rate, use of accessory muscles, paradoxical breathing, or the subjective feeling of being tired). Patients commonly excluded from a trail of NIV include those who wish no type of artificial support to extend life and those who are obtunded, uncooperative, lack a gag reflex, or are hemodynamically unstable. Failure to improve within 30 minutes of NIV signals the possible need for either endotracheal intubation or a decision to provide only medical management of symptoms. These are decisions that should be considered in the context of a discussion of goals of care. When NIV is used, the patient should still receive pharmacologic and nonpharmacologic therapies to relieve dyspnea.
Rapid Management of Severe Pain
Emergency physicians frequently treat pain and other symptoms. Like other specialists, they often undertreat pain and may not use a full range of therapies for symptoms other than pain.
Many emergency providers use a single standard 0.1 mg/kg morphine dose without frequent reassessment and without considering that some patients are opiate naive and others patients may be opiate tolerant. ED physicians and staff may be unfamiliar with how to calculate equianalgesic dosing for opiates, and especially they may be unfamiliar with the use of methadone for pain control. Many patients present at the ceiling of analgesia provided by oral acetaminophen with opiate preparations. Although some protocols exist for rapid titration of pain control in opiate-exposed patients, it is unknown how frequently these algorithms are used. Several dosing strategies for cancer pain have been described, but there is less research with opiate-naive patients in the emergency setting. Several published protocols for patients with cancer in the emergency setting include rapid titration protocols with morphine or fentanyl ( Figures 36-1 and 36-2 ). However, there are no published articles on short stays in the ED in which patients are transitioned from intravenous to long-acting oral opiates.
