Palliative care in the ED

Palliative care in the ED. Two things that does not seem to be related and even counter-intuitive! In the ED, we save lives right?! Right! But not at all price.

I did a presentation with a palliative care physician, Dr Russell Goldman from the Tammy Latner Center for Palliative Care about this topic and he taught me a few concepts that were eye-opening for me and I thought that I should share it.

To emphasize the importance of this, ACEP released a recommandation in 2013 for the “choosing wisely” campaign that says: “Don’t delay engaging available palliative care and hospice care services in the emergency department for patients likely to benefit.” Knowing this, it is important to try to find links with the palliative care services but also to target to right patient to engage your time with.

Let’s take a case: Ms Rydges, 92 years old, advanced dementia lives with her daughter, admitted twice in the last 6 months for pneumonia, came in this morning for fever and coughing. The chart says full code.

With this case, you have 3 options: the easy one with resuscitation and IV antibiotics and admission through medicine, comfort measure only, or something in between. Which one would you choose?

Palliative care is by definition management and relief of symptoms that interfere with quality of life. It does not always mean end of life care. As a matter of fact, palliative care physicians are involved in cancer patient very early in their course of disease for the purpose of symptoms management even if patients are having active treatment. Palliative care has also the role of coordination of care, psychological support, decision-making counseling  and simply good primary care medicine.

Why ED physicians are reluctant to engage in goals of care discussion? It is very easy to find a reason: time consuming, lack of appropriate physical space, absence of family or proxy, chaotic environment, patient agenda discrepancy, fear of confrontation discussion, to name a few. On the other hand, why the ED is a great opportunity for goals of care discussion? We are good with sx management (I absolutely not going to teach you how to treat pain or nausea or constipation or agitation). We are at the front line and we have a momentum on the acute decompensated disease. We have an interdisciplinary team availability and we are generally competent for crisis management. Plus, it can reduce LOS, ICU care, cost and improve patient satisfaction. It is good patient-centered care.

Who will likely benefit for an extra 15-20 minutes talk? (I can see 2-3 other patients instead…!). Smith in 2012 did a longitudinal study that showed that patients who ended up in palliative care, 75% visited the ED in their last 6 months, 51% in the last month, and most had repeated ED visits.Another study by Babcock showed a potential use of the palliative performance scale in the ED to predict life expectancy. Weissman in 2011 released a list of criteria for a palliative care assessment at the time of admission.

It can get very complicated but I will make it more simple for you and this is the first learning point: Anyone with a degenerative disease and/or older adults with a significant functional decline, are likely to benefit from a goals of care discussion.

So, part of your assessment should include a brief functional assessment (does Ms Rydges walks, eats, talks, how much care does she need, did it changed in the last year or 6 months?). If you are able to highlight a functional decline, it is worth the trial of a discussion.

The words you will choose (and I have a post about it) are not that important. You are all smart and empathic person, I trust that you will find a way to talk about goals of care discussion because my second learning point is that regardless of what you say, the patient or the family are the one that will indicate if you should talk about it more or stop and gives IV antibiotics for example. Let me explain.

Agreeing to palliative care is a very hard decision for the patient but also for families. It is a process that includes a few steps, the steps of change (pre-contemplation, contemptation, preparation, action, maintenance and relapse).

Let’s go back to our case to illustrate this concept.

You determined that Ms Rydges is bed-bound, does not communicate, stopped eating a few weeks ago. You decided that it is time to engage in a goals of care discussion (Good job!). The daughter could answer either:

1.Of Course I want IV antibiotics”

2.“I’ve been thinking a lot about that since her last admission. I’m not sure what to do anymore.”

3.“Things have gotten much harder for her lately, maybe it isn’t such a good idea anymore

On the first answer, you can see that she is in pre-contemplation mode. There is no way that you will go further with this palliative care discussion. You can only plant a seed and move on to the next patient.

On the second answer, the daughter is confused and may agree to comfort care if you make your case or if you engage the palliative care team. Probably worth your time.

On the third answer, easy. Organize a palliative care set up (outpatient vs inpatient).

By analyzing the family answers and try to put it on the “steps of change” scale, you are now able to evaluate which one is worth spending your time with.

To organize a palliative care set-up, there are a few options. Palliative care as an inpatient unit, as a consultant with the medicine team, as an outpatient with a home care based program, in long term care or nursing homes if they provide palliative care (they usually do), or hospices which is more of an american concept. Ask your hospital, invite the palliative care team to present to your service and ask for short cuts and links!

In summary, functional decline is what your are looking for in your assessment of potential palliative care patient, and try to analyze their answers to guide further discussions. I hope this will help because for me, it was revealing and very helpful for my day to day practice.

Now, are you feeling the geri-em transformation in you?! 🙂

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