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Hospice and palliative medicine, a subspecialty of emergency medicine, concentrates on life-threatening illnesses, whether curable or not.
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Palliative care is not the same as end-of-life (EOL) care.
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Arrival of a patient under hospice care to an emergency department (ED) does not automatically equate to hospice care termination nor does it imply that patient seeks aggressive interventions.
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Challenges to implementation of pre-existing advance planning documents exist, including an unanticipated
Palliative Medicine and Geriatric Emergency Care: Challenges, Opportunities, and Basic Principles
Section snippets
Key Points
Opening remarks
Before starting this article, it is important to have some perspective. Fig. 1, Fig. 2, Fig. 3 define the terms and summarize necessary concepts of care. On initial presentation of a disease, such as lung cancer or heart failure, the goal of care is curative but patients also receive noncurative symptom management. In cancer, this noncurative management may include nausea relief and relief of constipation. This noncurative symptom management is palliative. Palliative care is the relief of
Recognizing unmet palliative needs in the emergency department
Elderly patients with serious, advanced illnesses comprise a particularly vulnerable population in EDs.15, 21, 22, 23 A recent longitudinal study of patients older than 65 years examined the pattern of ED use in their last months of life23: 75% (4518 decedents) visited an ED in the last 6 months of life and 51% in the last month, and repeat visits to an ED were common.23 This is not unique to the United States; a recent Australian study of patients with a known poor prognosis disease, such as
Effective Communication when Caring for Seriously Ill ED Patients
Optimal communication with shared decision making has been identified by patients and families as a crucial aspect of medical care, especially at EOL.45, 46, 47, 48 Effective communication facilitates improved satisfaction with care and a reduction of anxiety and distress, often with even brief interactions.49, 50, 51 Although most patients and family members want to receive support and hope from clinicians, they also value clear and honest information about the medical condition and prognosis.
Palliative emergencies in the elderly
A palliative care emergency is an unexpected change in a patient's medical condition in the context of an underlying known advanced or serious illness, and this emergency often triggers an ED visit.34, 77, 78 The recommended ED assessment and treatment plan should consider patients' overall goals of care as well as the following:
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What is the acute medical issue and is it potentially reversible?
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What would most likely be the patient's status after treatment?
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What is the person's recent performance
Symptom management
The challenge faced by ED physicians who are managing patients with life-limiting illness, specifically EOL patients, is to provide relief of symptoms. Whether a patient is admitted to the hospital or discharged to home should not interfere with this management initiative. A partial list of common symptoms and complaints that may need to be addressed at EOL includes
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Agitation/confusion/delirium—see Table 3
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Anxiety
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Constipation—see Table 4
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Diarrhea
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Dyspnea
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Nausea and vomiting—see Table 5
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Pain—see
Ethical issues at EOL in the emergency department
“Palliative care at the EOL involves meeting the physical, psychological, social and practical needs of patients and caregivers.”81 Ethical issues arise from time to time in EDs when dealing with palliative care patients at the EOL. Ethical dilemmas in the ED setting are likely to include matters related to the use of artificial airways, artificial nutrition, and surrogate decision makers. If available, state-approved advanced directives in the form of do-not-resuscitate (DNR) orders, living
Managing the elderly under hospice care in the emergency department
Patients under hospice care often present to EDs for crisis events, and emergency clinicians who are familiar with the hospice model of care may be better able to guide EOL care for such patients.34 Eligibility for hospice is primarily based on a prognosis of living 6 months or less if the disease were to run its natural course.96 Patients may have any diagnosis to qualify for hospice care, and noncancer primary diagnoses now comprise more than half of all hospice admissions.96, 97
Arrival of a
Referring an eligible emergency department patient to hospice care
Elderly patients with declining health and functional status and advanced disease have frequent ED visits, particularly in the last months of life, presenting a window of opportunity to assess patient needs/goals of care and initiate discussions about hospice in eligible patients.35, 96, 100, 103, 106 Hospice may be considered in eligible patients when the pre-eminent care goal is relief of symptoms, such that they want therapy aimed at maintaining quality of life, without a major focus on life
Managing the actively dying patient in the emergency department
Two distinct death trajectories have been recently discussed in ED literature: the so-called spectacular death—a resource-intensive event, for example, a traumatic, sudden event in a young person where multiple personnel are involved, and the so-called subtacular death, for example, ED death of an older person with a DNR directive who enters the final actively dying phase after a prolonged chronic illness.106 Although it is important to give families a general idea of how long a patient might
Summary
It is impossible to put all aspects of palliative care into one article. The authors' objective is to give readers a broad overview of general principles. Geriatric care in EDs, by the nature of the specialty, must include an understanding of disease trajectory, prognostication, and symptom management in EOL as well as the psychosocial needs of dying patients and their families.
An understanding of palliative medicine is important for several reasons: palliative and hospice medicine is a
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Cited by (29)
The Geriatric-Focused Emergency Department: Opportunities and Challenges
2022, Journal of the American Medical Directors AssociationTen Best Practices for the Older Patient in the Emergency Department
2018, Clinics in Geriatric MedicineCitation Excerpt :ED patients with unmet palliative care needs include those with a potentially life-limiting condition and difficult to control symptoms, accelerated functional decline, complex outpatient care needs, or repeated recent ED visits or hospital admissions. Others benefitting from a palliative care approach include patients with out-of-hospital cardiac arrest, current or past hospice for palliative care involvement, incurable cancer, or those from long-term care facilities.40 Older adults present to the ED along a spectrum from increasing functional dependence to progressively intolerable symptoms, to impending respiratory or circulatory arrest.
An Approach to the Older Patient in the Emergency Department
2018, Clinics in Geriatric MedicineCitation Excerpt :Because ED-based palliative care consultations are rarely available, ED providers may best serve patients near the end of life by developing the primary palliative skills of communicating prognosis, eliciting values, reconciling goals to the acute situation, and making recommendations. These discussions are valuable for the patient and family, because clear communication is identified as both uncommon and important at end-of-life.27 In patients with severe acute symptoms and life-limiting illness, the ED discussion informs acute management, sets the trajectory for subsequent care, and facilitates subsequent discussion by introducing the patient and family to palliative approaches.
Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine
2016, Journal of Emergency MedicineCitation Excerpt :Since the first HPM certification examination was held in 2008, an increasing number of EPs have achieved board certification in the subspecialty (1,4). Over the last decade, emergency medicine (EM) has also taken a prominent role in integrating HPM-related practice principles into routine care of patients eligible for such services in the emergency department (ED) (2,5–9). The “Choosing Wisely” campaign (American College of Emergency Physicians [ACEP]) has highlighted the integrated disciplines, stating, “Don't delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit” (2,6,10).
Geriatric Emergency Department guidelines
2014, Annals of Emergency MedicineDemonstrations of clinical initiatives to improve palliative care in the emergency department: A report from the IPAL-EM initiative
2013, Annals of Emergency MedicineCitation Excerpt :In the last decade, integration of palliative care into EDs has achieved increasing focus, in part because of the ability of emergency physicians to become board certified in hospice and palliative medicine, as well as increasing acceptance of the need for an interdisciplinary team-based approach to care.3-6 Increasingly, palliative care initiatives in the ED that identify target populations and describe potential influences of these interventions are emerging.7-12 Improvement of palliative care services in the ED can occur with or without a hospital-based specialty palliative care consultation service; in other words, the lack of specialty palliative care services in a hospital is not necessarily a barrier to improved palliative care service delivery in the ED.
The authors have nothing to disclose.