Palliative Care in the Emergency Department:
New Specialty Weaving Into Acute Care Fabric
Article Outline
Dyspnea. Nausea. Dementia. The deep relentless pain of metastatic cancer.
Young physicians entering emergency medicine may envision spending their careers mending trauma victims and restarting stuttering hearts but soon find that they spend as much or more time treating chronically ill patients who cycle in and out of the emergency department (ED) with high symptom burdens and a grim trajectory that no one has stepped up to explain.
“In Detroit we have no shortage of gunshot wounds. But for every gunshot wound and acute injury that comes in, I have 2 patients from nursing homes, demented, in their 80s and 90s, that come in full code. And every patient I admit has been here a week before with similar complaints,” said Harsheel H. Desai, MD, the chief resident of emergency medicine at Sinai–Grace Hospital/Detroit Medical Center.
“I'm amazed it's allowed to happen,” he added.
Thanks to a small but growing nexus between emergency and palliative medicine, the skill set, the perceptions, the training, and the care are slowly changing.
In 2006, the American Board of Medical Specialties announced it would recognize palliative care as a specialty, with emergency medicine as one of 10 sponsoring fields. A small but growing number of emergency physicians have, or are seeking, dual certification through fellowships or midcareer educational programs.
In addition, a sort of “cross-fertilization” is occurring between palliative and emergency medicine nationally and locally, formally and informally. It can be as structured as a train-the-trainer course of the Education in Palliative and End-of-Life Care in Emergency Medicine Project (EPEC-EM) or as spontaneous as 2 emergency physicians, one with palliative training and the other open to learning, clicking through “Google Scholar” at 2 am, looking at what palliative care offers a 73-year-old man with metastatic gastric cancer, failing kidneys, an intestinal blockage—and a family that expects a complete recovery.
More than Mortality
Palliative care doesn't only mean comfort care for the imminently dying, or referrals to hospice, although that is certainly an aspect. It doesn't mean that patients have to give up their chemotherapy or their access to the ICU. It does encompass control of pain and management of distressing symptoms such as severe nausea or shortness of breath. It means the ability to break bad news when that headache turns out to be a brain tumor or that fracture means the breast or prostate cancer has spread. It means helping families who are trying to make clear and wise decisions while coping with shock and grief, explaining that “stable” is not physician-speak for “getting better,” let alone “fine and dandy.”
“Everybody has an invisible threshold of how much of a burden they can take being treated in the hospital. You need, and you have, the option of a less aggressive, more comfort-driven path. I think everyone, patients and families, deserves that option,” said Robert Zalenski, MD, a mentor to Dr. Desai and the founder and director of the Wayne State Division of Palliative Emergency Medicine. Dr. Zalenski's own professional trajectory from “pure” emergency medicine to an emergency medicine-palliative care hybrid arose from 2 personal losses: the death of his baby daughter after 10 harrowing months and the gentle “very ‘Tuesdays With Morrie,' very positive” way his father died 6 years later, with closure, peace, and hospice.
Palliative training for the ED doesn't mean that every emergency physician needs to become a full-fledged specialist. But Michael A. Gisondi, MD, director of the emergency residency program and assistant professor, Department of Emergency Medicine at Northwestern University Feinberg School of Medicine, wants all the physicians in his ED to have core competencies, the ability to provide what he calls “primary palliative care,” including excellent care for patients who are dying in the ED.
For complex cases, or for situations when palliative care needs can't be addressed in a frenetically busy, privacy-lacking, crisis-driven ED, Dr. Gisondi calls in the hospital's palliative care service for a consultation, forming a partnership that has deepened the skills and understanding of residents and attending physicians in both fields.
“They began calling us 4 or 5 years ago, like any other service, saying ‘Can you help us?’” said Joshua Hauser, MD, an assistant professor of medicine and palliative care at Northwestern and a colleague of Dr. Gisondi. “Some of these patients, they've come in over and over and over again, they've been seen by 6 different emergency medical teams, 6 different medical inpatient teams, an ICU, and a handful of outpatient cardiologists. There aren't a lot of options, but the therapies keep going on because no one ever said, ‘Can we consider something else?’ Sometimes, it surprises us [that] the family is on board. They've just been waiting for someone to talk to them.”
But palliative care services aren't yet available in all hospitals or all communities. Nor is it always embraced.
“There are barriers from the provider side,” said Corita Grudzen, MD, MSHS, assistant professor of emergency medicine at Mt. Sinai School of Medicine in New York, whose research focuses on ED-based palliative care for older adults. “There are people who get it, and there are some who don't get it or say ‘I don’t believe in palliative care.'”
There are barriers on the financial side, too. “You get paid more to sew up a laceration, but there's no billing for talking to a family after death. And that is such hard and intense work,” Dr. Grudzen added.
A Culture Change
New payment models and more integrated care models under health reform may slowly begin to change the financial incentives. Teaching palliative care in the lecture hall and at the bedside has begun to change the culture.
“I trained at NYU with both guns blazing,” said Susan Stone, MD, MPH, who is now at Cedars-Sinai in Los Angeles but who introduced palliative care at Los Angeles County–University of Southern California Medical Center. “I never had any idea I was going to do anything about end-of-life care; it wasn't even a twinkle in my eye.”
Practicing in a safety-net, Los Angeles ED opened her eyes, and her own ongoing struggle with leukemia changed her professional focus. She does a lot of lecturing and teaching now, in California and beyond, and in a few short years has seen growing acceptance of palliative medicine. Not all emergency physicians can or will do it themselves, particularly in a place as crowded and busy as Los Angeles County, but they will certainly call for a consultation. A few years ago, she said, colleagues had misperceptions about palliative care, “but now everyone is climbing on board.”
Although palliative care training is not de rigueur in emergency medicine residencies, a smattering of programs is incorporating aspects in disparate settings. At Stanford, Garrett Chan, RN, PhD, teaches emergency residents about breaking bad news, particularly in pediatrics. He also has a particular interest in addressing shortness of breath. At Northwestern, all residents now spend a full month learning about palliative care, including a field trip to a long-term care facility, the other side of their patients' revolving door. (Dr. Gisondi and colleagues have developed a version of the EPEC-EM curriculum, a mix of didactic and online self-learning modules, for use in other institutions, which has been accepted for publication in the Western Journal of Emergency Medicine.) In Detroit, for the first 2 years of his residency, Dr. Desai absorbed lessons about palliative care from Dr. Zalenski. In his third year, he spent a week in the palliative care inpatient unit and with the palliative care consultation service, an experience that used to be elective and is now mandatory.
That experience changed not only how Dr. Desai thinks about patients but also how he talks to them, and about them. He's less likely to ask the family of one of his nursing home “revolving door” patients, “Would you like us to help her breathe?” and more likely to describe, precisely but not unkindly, how a sick frail old person will feel when “I shove this large tube down her throat.” He refers to patients by their first name and helps families come to understand that no matter what switches or buttons he pushes, he can't undo 20 years of decline. “She won't be the Mary you remembered,” he'll say.
Tammie Quest, MD, one of the most prominent educators and practitioners at that intersection of palliative and emergency medicine, divides her time between Grady Health System, the Atlanta VA Medical Center, and Emory Hospital and School of Medicine. When she's in the ED, she treats asthma and heart attacks and blood clots and strokes, everything and anything that crosses her path. But she also sees the palliative care needs. That gastric cancer patient, the one who inspired Dr. Quest to pull up those Google Scholar articles for her Emory ED colleague Ryan Armstrong, MD, MEd, illustrates how her 2 disciplines intersect.
The patient was a 73-year-old who had been diagnosed 2 months earlier at another, smaller Atlanta hospital. Either those oncologists had not explained or his family had not grasped that his gastric cancer had spread extensively, that they might be able to slow it down but that they could not cure him. Nor did they prescribe narcotics for the pain; another hospital would prescribe an opiate just 1 day before he ended up in Emory's ED with failing kidneys and an intestinal blockage. Dr. Quest wasn't sure she could get him through the night. The family expected a complete recovery.
Dr. Quest and her team worked exhaustively to get his kidneys working again, not because Dr. Quest harbored delusions about a cure but because she thought that with good palliative care, along with whatever cancer treatment the oncologists still deemed appropriate, he could have more time. “I think he's got 2 or 3 more good months,” Dr. Quest explained to Dr. Armstrong before gently but clearly laying out the situation to the family gathered around the bedside. “I want him to have them.”
Beyond “Just Do It”
The next day, she flew to Chicago to teach an EPEC-EM course. The program, funded by the National Cancer Institute, has trained more than 140 physicians, nurses, social workers, and chaplains, who in turn have trained thousands of other ED clinicians and personnel, in the United States and abroad. They range from experienced physicians who direct leading emergency medicine residency programs to young physicians realizing that their “just do it” emergency instincts were not always the best approach for their patients.
EPEC-EM is an intensive immersion during a couple of days; some emergency physicians take a year-long plunge. Tommy Morel, MD, had learned a bit about palliative care at medical school at Louisiana State University. He didn't choose Virginia Commonwealth University Medical Center for his emergency medicine residency because of its nationally recognized palliative care program, but it caught his attention once he got there. He's now completing a fellowship in palliative care. Dr. Morel readily admits he might not have gone that route had he not needed to stay in Richmond a fourth year while his wife completed her obstetrics/gynecology residency.
But the experience has been transformative. Not only has he acquired skills he didn't have before but also they are skills he didn't even know he lacked.
“It's like looking at a painting and not just appreciating its beauty but the technique, the brush strokes,” Dr. Morel said. “It's a whole new way of looking at a patient.”
Dr. Morel has also been a 1-man ambassador between palliative and emergency care; consultations had occurred for years, but the numbers have soared since he's been upstairs. “He's very effective. He's one of them. He speaks their language,” said Patrick Coyne, MSN APRN, clinical director of the Thomas Palliative Care Services/VCU Massey Cancer Center, a national leader in palliative care and training.
“In the ER, we think ‘I get paid to save lives,'” Dr. Morel said. “It was never part of their [attending emergency physicians'] DNA to think about palliative care or how to incorporate it in their practice.” Now they turn to him often and quickly, sometimes even before the ambulance has arrived.
“Then we can have a bedside teaching moment,” Dr. Morel said. “It can have more impact than a lecture.”
Dr. Gisondi doesn't expect hospitals to beat down his door to implement his palliative care-emergency medicine curriculum, or every physician to stampede to hear him and his colleagues at EPEC-EM. System-wide change may take years and may not come until regulatory bodies step in and demand better palliative care in the emergency setting, or until those “primary palliative care” competencies are written into the board certification examinations.
Wayne State's Dr. Zalenski likes to envision change coming another way: “From bands of physicians who just love this work.”
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
PII: S0196-0644(10)01640-9
doi:10.1016/j.annemergmed.2010.10.002
