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Clin Exp Emerg Med > Volume 9(3); 2022 > Article
Chang, Espinosa, Lucerna, and Parikh: Palliative and end-of-life care in the emergency department


With current medical advances, the human population continues to age. This presents healthcare practitioners with the increasing complexity of providing care to elderly patients with multifactorial medical and personal needs. This is a particular challenge in the emergency department, where patients often present for care in the last months of their lives. Early identification of palliative care needs and initiation of comfort care can drastically improve patient care and quality of life. Although emergency physicians agree that palliative care is an important area of knowledge, there is a gap in palliative care training in emergency medicine residencies. It is increasingly important for emergency medicine providers to have the resources and training to provide palliative care and to understand end-of-life issues.


With current medical advances, the human population continues to age. This is a growing challenge, particularly in the emergency department (ED), where patients often present in the last months of their lives. A study conducted by the University of California San Francisco indicated that 75% of patients visited the ED in their last 6 months of life [1]. A study has shown that 56% to 99% of older adults do not have advance directives available at ED presentation [2]. Therefore, ED visits toward the end of life are opportune teaching moments for emergency physicians to empower patients who are still well enough to communicate their goals and choices. In addition, 77% of patients seen in the ED during the last month of life were admitted to the hospital, and 68% of those admitted died there. In contrast, patients who enrolled in hospice at least 1 month before death rarely visited the ED during that time period. Most people say they prefer to receive end-of-life care at home. Early identification of palliative care needs and initiation of comfort care can improve quality of life, decrease in-hospital mortality, decrease ED visits, and decrease hospital costs [3]. Therefore, it is increasingly relevant for emergency medicine (EM) providers to have the resources needed to provide palliative and end-of-life care.


The Model of the Clinical Practice of Emergency Medicine includes health care coordination at the end of life and palliative care as essential skills for emergency physicians [4]. According to the American College of Emergency Physicians, the core topics of palliative care relevant to EM are recognition of palliative care and hospice needs in patients, primary-level provider skills in palliative care, and an understanding of how palliative care can be implemented in the ED [5,6]. ED initiation of palliative care is helpful because patients who participated in palliative care conversations in the ED have higher incidence of inpatient palliative consultation and shorter time to a palliative care consultation compared to traditional ED care [7]. Inpatient palliative care consultation within 24 hours is associated with shorter hospital stay, decreased total cost of hospitalization, and decreased in-hospital mortality. However, emergency physicians are only responsible for 3% of palliative care referrals. In a survey that asked medical residents how comfortable they are with end-of-life discussions, 26% stated they were not comfortable with such discussions [8,9].


A literature review identified several barriers to palliative care in the ED, including lack of prior provider-patient relationships, uncertain knowledge about prognosis, lack of time, lack of access to medical records, and lack of availability of a palliative care team [10]. There is evidence of discrepancy between the perceived importance of palliative care skills and medical resident training. A survey of emergency physicians showed that 88% of residents agreed or strongly agreed that palliative care skills are an important competency for EM [11]. Of the respondents in the study, 79% stated they would like to receive more training and education in palliative care, 46% reported minimal training in managing the imminently dying, and 54% reported minimal training in managing hospice patients.


The literature indicates significant advantages of early palliative care in management of patients with life-limiting or chronically debilitating disease. For older adults with serious illness, advanced care planning conversations are associated with improved quality of life, earlier hospice referral, lower in-hospital death, and greater likelihood of wishes known and followed [12]. Moreover, for caregivers, early end-of-life conversations are associated with better bereavement adjustment, reduced trauma, and distress in decision-making [13,14]. Many patients with serious, life-limiting illness have a high incidence of ED visits, especially during the last months of life [15]. Therefore, it is increasingly important to recognize the ED as an opportunity to have advanced care planning discussion and the development of end-of-life care plans. These decisions have a profound impact on patient care. However, while there is an acknowledgement of the importance of palliative care skills in EM, there is a significant gap in palliative care training for EM residents.
Successful implementation of palliative care screening tools has shown positive outcomes in patient care. One medical center has developed a set of evidence-based screening criteria and algorithms to identify patients who might benefit from earlier palliative care involvement. In the post-implementation survey, staff reported increased confidence in palliative care skills and a 400% increase in palliative care consult requests [15]. A study using an ED-based, brief negotiated interview to stimulate conversations showed improved palliative care engagement. The duration of such ED interventions averaged 11.8 minutes [16].


Currently, there are multiple screening tools available for identifying palliative care patients that can be effectively integrated into the ED [17]. Of note, the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED) is a 13-symptom assessment tool that demonstrated high reliability in identifying palliative care patients in the ED [18]. A retrospective cohort study on the CARING criteria (Cancer, Admissions ≥2, residence in a nursing home, Intensive care unit admit with multiorgan failure, ≥2 Noncancer hospice Guidelines) demonstrated that they were highly predictive of death at 1 year in a hospitalized veteran population [19]. Even the simple question, “Would I be surprised if this patient dies in the next 12 months?” is highly predictive of death within 1 year, with a prospective cohort study demonstrating a positive predictive value of 84% [20].


As our population ages, the early incorporation of palliative care as a part of patient care is increasingly urgent. The literature shows significant benefits of palliative care for patients, their families, and the healthcare system. Studies have shown that the ED can play an important role in addressing the palliative care needs of patients with serious illnesses. Beyond equipping healthcare workers in the ED with tools to recognize patients who can benefit from palliative care, it is essential to empower EM physicians with the required skills to engage patients in advanced care planning and end-of-life care conversations. This can be addressed by closing the gap of palliative care training in EM residencies. Studies have shown that early palliative care interventions in the ED can effectively change the trajectory of patient care. They also can reduce the burden on the healthcare system by reducing ED visits, intensive care unit admissions, and length of stay. More importantly, they allow seriously ill patients to reflect on their end-oflife wishes.


No potential conflict of interest relevant to this article was reported.


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