Skip to main content

Capacity Building: Integration of Palliative Care in Emergency Medicine

  • Chapter
  • First Online:
Oncologic Emergency Medicine

Abstract

The emergency department (ED) cares for many seriously ill patients, including those with oncologic emergencies. In the seriously ill, ED visits tend to increase as the patient’s status deteriorates and as they approach the end of life. A collaborative approach between oncology, palliative care and emergency care providers has the potential to optimize patient care. This includes aligning patient and family goals with treatment plans and ensuring a smooth transition across care settings. Emergency medicine is increasingly taking a prominent role in integrating palliative care into emergency practice. For most seriously ill patients, their basic palliative care needs such as symptom control will likely be adequately met at the generalist level of palliative care provided by the ED providers. However, some patients with more complex issues and difficult-to-manage symptoms may need specialist level of palliative care delivered by providers with expertise and training in palliative medicine. This chapter outlines the role of ED palliative care in managing oncologic emergencies in the seriously ill patient. Initiatives such as the national Integrating Palliative Care into Emergency Medicine (IPAL-EM) project and other current models of ED palliative care integration are described. Finally, a stepwise approach to jump-start such an integration initiative is outlined for clinicians and administrators of programs that seek to optimize care for the seriously ill ED patient.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6):563–8.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Vandyk AD, Harrison MB, Macartney G, Ross-White A, Stacey D. Emergency department visits for symptoms experienced by oncology patients: a systematic review. Support Care Cancer. 2012;20(8):1589–99.

    Article  PubMed  Google Scholar 

  3. Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2014;22(2):315–21.

    Article  Google Scholar 

  4. Leak A, Mayer DK, Wyss A, Travers D, Waller A. Why do cancer patients die in the emergency department? An analysis of 283 deaths in NC EDs. Am J Hosp Palliat Med. 2013;30(2):178–82.

    Article  Google Scholar 

  5. Smith AK, Schonberg MA, Fisher J, Pallin DJ, Block SD, Forrow L, et al. Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manage. 2010;39(6):972–81.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42.

    Google Scholar 

  7. Lamba S, DeSandre P, Todd K, et al. Integration of palliative care into emergency department: the IPAL EM collaboration. J Emerg Med. 2014;46(2):264–70.

    Article  PubMed  Google Scholar 

  8. Hui D, Kim YJ, Park JC, Zhang Y, Strasser F, Cherney N, et al. Integration of oncology and palliative care: a systematic review. Oncologist. 2015;20:77–83.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Nauck F, Alt-Epping B. Crises in palliative care—a comprehensive approach. Lancet Oncol. 2008;9(11):1086–91.

    Article  PubMed  Google Scholar 

  10. Jelinek GA, Marck CH, Weiland TJ, Philip J, Boughey M, Weil J, et al. Caught in the middle: tensions around the emergency department care of people with advanced cancer. Emerg Med Australas. 2013;25(2):154–60.

    Article  PubMed  Google Scholar 

  11. Burge F, Lawson B, Johnston G. Family physician continuity of care and emergency department use in end‐of‐life cancer care. Med Care. 2003;41(8):992–1001.

    Article  PubMed  Google Scholar 

  12. Wiese CH, Vossen-Wellmann A, Morgenthal HC, Popov AF, Graf BM, Hanekop GG. Emergency calls and need for emergency care in patients looked after by a palliative care team: retrospective interview study with bereaved relatives. BMC Palliat Care. 2008;7(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kenen J. Palliative care in the emergency department: new specialty weaving into acute care fabric. Ann Emerg Med. 2010;56(6):A17–9.

    Article  PubMed  Google Scholar 

  14. Chan GK. End-of-life models and emergency department care. Acad Emerg Med. 2004;11:79–86.

    Article  PubMed  Google Scholar 

  15. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med. 2009;54(1):86–93. 93.e1.

    Article  PubMed  Google Scholar 

  16. Lamba S, Mosenthal AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine. J Emerg Med. 2012;43(5):849–53.

    Article  PubMed  Google Scholar 

  17. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94–102.

    Article  PubMed  Google Scholar 

  18. Lamba S. Early goal-directed palliative therapy in the emergency department: a step to move palliative care upstream. J Palliat Med. 2009;12:767.

    Article  PubMed  Google Scholar 

  19. Meier DE, Beresford L. Fast response is key to partnering with the emergency department. J Palliat Med. 2007;10:641–5.

    Article  PubMed  Google Scholar 

  20. Lamba S, Quest TE, Weissman DE. Initiating a hospice referral from the emergency department #247. Fast Facts and Concepts. J Palliat Med. 2011;14(12):1346–7.

    Google Scholar 

  21. Mahony SO, Blank A, Simpson J, et al. Preliminary report of a palliative care and case management project in an emergency department for chronically ill elderly patients. J Urban Health. 2008;85(3):443–51.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Quest TE, Herr S, Lamba S, Weissman DE. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM initiative. Ann Emerg Med. 2013;61(6):661–7.

    Article  PubMed  Google Scholar 

  23. World Health Organization. Definition of palliative care. World Health Organization Web site. Available at: http://www.who.int/cancer/palliative/definition/en/. Last accessed 1 Mar 2015.

  24. Morrison RS, Meier DE. Clinical Practice. Palliative care. N Engl J Med. 2004;350(25):2582–90.

    Article  CAS  PubMed  Google Scholar 

  25. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22–8.

    Article  PubMed  PubMed Central  Google Scholar 

  26. National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. 2nd ed. Pittsburgh, PA: National Consensus Project; 2009. Available at: http://www.nationalconsensusproject.org/guideline.pdf. Last accessed 2 Mar 2015.

    Google Scholar 

  27. Twaddle ML, Maxwell TL, Cassel JB, et al. Palliative care benchmarks from academic medical centers. J Palliat Med. 2007;10(1):86–98.

    Article  PubMed  Google Scholar 

  28. Meier DE. Increased access to palliative care and hospice services: opportunities to improve value in health care. Milbank Q. 2011;89(3):343–80.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Fadul N, Elsayem A, Palmer JL, et al. Supportive versus palliative care: what’s in a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2000;115(9):2013–21.

    Article  Google Scholar 

  30. Glajchen M, Lawson R, Homel P, DeSandre P, Todd KH. A rapid two-stage screening protocol for palliative care in the emergency department: a quality improvement initiative. J Pain Symptom Manage. 2011;42(5):657–62.

    Article  PubMed  Google Scholar 

  31. Lawson BJ, Burge FI, McIntyre P, Field S, Maxwell D. Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients? J Palliat Med. 2009;12(3):245–52.

    Article  PubMed  Google Scholar 

  32. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life Institute of Medicine report 2014. Available at: http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx. Last accessed 2 Mar 2015.

  33. Morrison RS, Penrod JD, Cassel JB, Caust-Ellenbogen M, Litke A, Spragens L, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783–90.

    Article  PubMed  Google Scholar 

  34. Morrison RS, Dietrich J, Ladwig S, Quill T, Sacco J, Tangeman J, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff. 2011;30(3):454–63.

    Article  Google Scholar 

  35. Penrod JD, Deb P, Luhrs C, Dellenbaugh C, Zhu CW, Hochman T, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855–60.

    Article  PubMed  Google Scholar 

  36. Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc. 2007;55(7):993–1000.

    Article  PubMed  Google Scholar 

  37. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Connors AF, Dawson NV, Desbiens NA, Fulkerson WJ, Goldman L, Knaus WA, et al. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591–8.

    Article  Google Scholar 

  39. Lamba S, Nagurka R, Zeilinski A, Scott SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med. 2013;16(2):143–7.

    Article  PubMed  Google Scholar 

  40. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173–5.

    Article  CAS  PubMed  Google Scholar 

  41. Gamondi C, Larkin P, Payne S. Core competencies in palliative care: an EAPC white paper on palliative care education: part 2. Eur J Palliat Care. 2013;20(3):140–5.

    Google Scholar 

  42. Morrison RS, Maroney-Galin C, Kralovec PD, Meier DE. The growth of palliative care programs in United States hospitals. J Palliat Med. 2005;8(6):1127–34.

    Article  PubMed  Google Scholar 

  43. Agency for Healthcare Research and Quality. HRQ Quality Indicators. http://www.qualityindicators.ahrq.gov/news/EDPerformanceMeasures-ConsensusStatement.pdf. Last accessed 2 Mar 2015.

  44. Emanuel LL, Ferris FD, Von Gunten CF. EPEC. Education for physicians on End-of-Life Care. Am J Hosp Palliat Care. 2002;19:17.

    Article  PubMed  Google Scholar 

  45. End-of-Life Nursing Education Consortium. Available at: http://www.aacn.nche.edu/elnec. Last accessed 2 Mar 2015.

  46. Vital talk. Quick Guides. Available at: http://www.vitaltalk.org/quick-guide. Last accessed 2 Mar 2015.

  47. Onco Talk Learning Modules. Available at: http://depts.washington.edu/oncotalk/modules.php. Last accessed 2 Mar 2015.

  48. Pain and policies study group: State Continuing Education Policies for Pain and Palliative Care. Available at: http://www.painpolicy.wisc.edu/state-continuing-education-policies-pain-and-palliative-care. Last accessed 2 Mar 2015.

  49. Improving Palliative Care in Emergency Medicine; IPAL-EM project. Center to Advance Palliative Care. Available at: https://www.capc.org/ipal/ipal-emergency-medicine/. Last accessed 2 Mar 2015.

  50. Lamba S, Schmidt T, Grudzen C, Chan GK, Todd K, Quest TE. Integrating palliative principles in the out-of-hospital setting: four things to jump start an EMS-palliative care initiative. Prehosp Emerg Care. 2013;17(4):511–20.

    Article  PubMed  Google Scholar 

  51. Fine RL. The imperative for hospital-based palliative care: patient, institutional, and societal benefits. Proc (Bayl Univ Med Cent). 2004;17(3):259–64.

    Google Scholar 

  52. Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med. 2013;14(6):633–6.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Grudzen CR, Richardson LD, Major-Monfried H, Kandarian B, Ortiz JM, Morrison RS. Hospital administrators’ views on barriers and opportunities to delivering palliative care in the emergency department. Ann Emerg Med. 2013;61(6):654–60.

    Article  PubMed  Google Scholar 

  54. Lamba S, Pound A, Rella JG, Compton S. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med. 2012;5(5):516–20.

    Article  Google Scholar 

  55. Choosing Wisely Campaign. Available at: http://www.choosingwisely.org/nations-emergency-physicians-announce-list-of-test-and-procedures-to-question-as-part-of-choosing-wisely-campaign/. Last accessed 2 Mar 2015.

  56. American College of Emergency Physicians. Ethical issues in emergency department care at the end of life. Ann Emerg Med. 2006;47(3):302.

    Article  Google Scholar 

  57. Emergency Nurses Association (ENA) Position Statement on End-Of-Life Care in the Emergency Department. Available at: http://www.ena.org/SiteCollectionDocuments/Position%20Statements/EndofLifeCareintheEmergencyDepartment.pdf. Last accessed 2 Mar 2015.

  58. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17–23.

    Article  PubMed  Google Scholar 

  59. Gisondi MA. A case for education in palliative and end-of-life care in emergency medicine. Acad Emerg Med. 2009;16:181–3.

    Article  PubMed  Google Scholar 

  60. Fast Facts. Available at: https://www.capc.org/fast-facts/. Last accessed 2 Mar 2015.

  61. Lamba S, Quest TE, Weissman DE. Initiating a hospice referral from the emergency department #247. Fast Facts and Concepts. J Palliat Med. 2011;14(12):1346–7.

    Google Scholar 

  62. Accreditation Council for Graduate Medical Education (ACGME)—Public. Program Search, Hospice and Palliative Medicine fellowship programs. Available at: https://www.acgme.org/ads/Public/Programs/Search?specialtyId=153&orgCode. Last accessed 2 Mar 2015.

  63. Chan GK, Bryant EN, Lamba S, Quest TE, Weissman DE, Todd KH. Clinical practice guidelines-self assessment tool. A technical assistance resource from the IPAL-EM project. Center to Advance Palliative Care. Available at: https://www.capc.org/ipal/ipal-emergency-medicine/. Last accessed 2 Mar 2015.

  64. Quest TE, Asplin BR, Cairns CB, Hwang U, Pines J. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med. 2011;18(6):e70–6.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sangeeta Lamba MD, MS HPEd, FACEP, FAAHPM .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Lamba, S. (2016). Capacity Building: Integration of Palliative Care in Emergency Medicine. In: Todd, K., Thomas, Jr., C. (eds) Oncologic Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-26387-8_42

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-26387-8_42

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-26385-4

  • Online ISBN: 978-3-319-26387-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics