Alexandra Stoia Rusu
Palliative care is defined by the WHO as a multidisciplinary approach that improves the quality of life of the patient facing life-threatening illness and the quality of life of caregivers. Palliative care should be a team effort that addresses both the patient’s and their family’s problems and this team is usually made up of doctors, nurses, psychotherapists or hospital specialists to reduce symptoms and increase quality of life (1).
Services included in palliative care are the following:
- Specific medical services- to identify physical, psychological, social and spiritual needs of the patient and family and to make a specific care plan for each patient;
- Management of physical and emotional symptoms;
- Nursing services;
- Specific therapies: physiotherapy, occupational therapy, psychological therapy;
- Social services: medical devices, financial help;
- General information – for patients and carers on available services (2).
Palliative care is an interdisciplinary and multi-professional activity that adapts to the needs of the patient. Palliative care services and policies should offer a wide range of resources, such as home care, care in specialized inpatient units (hospice) or conventional units, day care centre or specialized outpatient, emergency services or “respite units”. These will be comprehensive and appropriate services to culturally and health systems, and will be oriented towards the changing needs of patients and their families.
As palliative care is not an approach that can be provided by a single healthcare provider, it cannot be provided by a single healthcare institution. To implement palliative care in its full sense, all structures of a country’s health system are needed. All palliative care providers should be determined and communication between providers should be maintained. There may be variations according to a country’s health system. These may be palliative care units, home care teams or consultants in hospitals, hospices, primary care providers and emergency departments.
Emergency physicians should be aware of these palliative care providers, especially for referring these patients from the emergency department (3). Referring patients to hospice care is an important decision in the emergency department. Four steps have been suggested as assessing eligibility for hospice benefits, discussing hospice as a disposition plan with the patient’s physician, assessing whether the patient’s goals are consistent with hospice care, and hospice placement for the patient and their caregivers (4).
Palliative care in the emergency department
There are large gaps in the provision of palliative care in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. In addition, outpatient clinics and GP practices are not suited to treat pain or other symptoms such as vomiting or dyspnoea, as most do not have the capacity to provide emergency care, and if they do, it is only during normal working hours. The emergency department is often the only place that can provide necessary interventions (IV fluids, pain medication), as well as immediate access to advanced diagnostic testing 24/7.
It is well known that patients in need of palliative care often are presented to the emergency department, whether or not palliative care units, home care services and hospices are available. High rates of presentations to emergency departments (ER) in the last weeks of life are indicators of poor quality end-of-life care (5).
Patients come to emergency departments for relief of pain and other distressing symptoms. Increasingly, these patients are old and complex from medical point of view, requiring greater skills in providing palliative care services.
There are multiple situations for which terminally ill patients present to the emergency department. First, they may have severe and varied symptoms in the trajectory of an illness. Pain is the most common problem. In addition to pain, dyspnoea, nausea, vomiting, nutritional deficiencies, fatigue, bleeding, anaemia, insomnia, pruritus, constipation, fever may occur.
The emergency department may be an option for these patients for hydration, administration of intravenous medication, for rapid imaging accessibility. The symptoms the patient suffers from are often disturbing and upsetting and can cause anxiety for patients and caregivers. It has been found that many patients in advanced stages of malignancy who present to ER need only simple procedures such as hydration, urinary catheterisation and oxygen therapy.
Emergency departments will always be essential for palliative care patients, with or without palliative care units, hospices or palliative care consultants. The first important point in providing the best care is to be aware of the importance of palliative care in the emergency department. These types of patients are on a long and difficult journey. They are more vulnerable than other patients, therefore symptom-oriented assessments may not be enough for them. Emergency department visits can distress and exhaust vulnerable end-of-life patients and their families, while being clinically difficult and time-consuming for medical staff (6).
Training of emergency medical staff is very important. A lack of training addressing palliative care in emergency medicine residency programs is mentioned in the literature.
The benefits of integrating palliative care into the emergency department
Creating a palliative care pathway in the emergency department provides a better match of care to patient wishes and can provide an improvement in patient-centred care and a decrease in intensity and invasiveness of care. The initiation of palliative care in the ER has been shown to provide multiple benefits in terms of timely delivery of care, promoting quality of life and reducing costs associated with treatments, direct referrals to hospice, reduced length of hospital stay, patient and family satisfaction.
It has been shown that patients who spent more time with home care teams had fewer emergency department presentations (7). Special palliative care programs in health care systems can reduce psychosocial stress in families as well as the number of 112 calls (8).
Some basic steps for integrating palliative care in the emergency department:
– The first step is to set up an interdisciplinary working group to plan and lead the operation;
– The second step is to assess the needs and resources for improving palliative care in the emergency department;
– The third step is to develop an action plan to establish work responsibilities and a timeline;
– Step four is engaging the whole team to create a culture of support for improving palliative care (9).
In a study by Rosenberg, an integration model called “Life Sustaining Management and Alternatives” is presented. It is an emergency palliative care program that includes a core team of an emergency physician and a nurse coordinator for initial consultation. Other team members include nutritionists, chaplains, psychologists, social workers, physiotherapists, occupational therapists and other disciplines needed to meet the needs of each patient. The study reports increased patient and family satisfaction, reduced costs, reduced intensity of care and reduced resuscitation rates with the LSMA program (10).
Emergency service providers, as well as the palliative care community, have increasingly recognized the need to provide palliative care services in the emergency department (11). Every emergency department should be organized according to the health care resources in the country, the resources of hospitals, with or without consultants or palliative units, and the circumstances of each emergency department. Thus, the methods might be different, but the aim should be to present high-quality care for terminally ill patients.
When a patient is presented to an emergency department the first question should be “What is the appropriate treatment for this patient in this particular situation?” After evaluation and treatment, the emergency physician, the patient, the patient’s family and the patient’s family physician should decide the best option between hospice, hospital or home care.
Emergency physicians should have the basic competences related to palliative care. According to a study by Meo et al, these competencies are: assessing disease trajectory, formulating prognosis, communicating with patients and families, managing pain and symptoms, withdrawing or stopping treatments that are not in the benefit of the patient, advanced care planning, understanding ethical and legal issues. These core competencies can be added to emergency medicine residency programs.
List of solutions for providing the best palliative care in emergency services:
- Arrangements that include facilities for the provision of palliative care that can be made within the existing healthcare system;
- Training programmes that include core palliative care competencies to be added to residency programs;
- Management guidelines that include emergency situations in palliative care can be prepared for emergency staff;
- Palliative care educational materials and courses that can be added to continuous medical education;
- Special palliative care teams in emergency departments.
Palliative care has shown to improve the quality of life of the patient and family members significantly, to reduce distressing symptoms, to improve the quality of care, to reduce length of hospital stay and healthcare costs overall, and to reduce mortality in case of metastases (12).
Institute of Medicine and National Research Council from Washington has highlighted many of the barriers to improving end-of-life care, including the historical separation of palliative or hospice care from potentially life-prolonging therapies (13). Integrating palliative care into the emergency department, a place designed more to intervene than to alleviate, is a start to breaking down these barriers. The number of emergency department-based pilot programs in the United States continues to grow, and preliminary data show associated reductions in hospital length of stay and per-day costs. From a quality and cost-benefit perspective, providing palliative care services in the emergency department early in the hospital course could provide an even greater benefit to patients, families, and hospitals than inpatient consultation, which often occurs late in a patient’s hospital trajectory (14,15).
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- WHO Definition on Palliative Care. World Health Organization. Available from: https://www.who.int/health-topics/palliative-care [Accessed 10th june 2022].
- Blinderman CD, Billings JA. Comfort Care for Patients Dying in the Hospital. N Engl J Med. 2015;373(26):2549-61. Available from: doi: 10.1056/NEJMra1411746.
- JA Greer, VA Jackson, DE Meier, JS Temel. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin 2013;63;349-363.
- S Lamba, TE Quest, DE Weissman. Initiating a hospice referral from the emergency department #247. J Palliat Med 2011;14:1346-1347.
- BA McNamara, LK Rosenwax, K Murray, DC Currow. Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death. J Palliat Med 2013;16:774-779.
- Marck CH, Weil J, Lane H, Weiland TJ, Philip J, Boughey M, Jelinek GA. Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians. Intern Med J. 2014;44(4):362-8. Available from: doi: 10.1111/imj.12379.
- Seow H, Barbera L, Howell D, Dy SM. Using more end-of-life homecare services is associated with using fewer acute care services: a population-based cohort study. Med Care. 2010;48(2):118-24. Available from: doi: 10.1097/MLR.0b013e3181c162ef.
- 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;7:11. Available from:doi: 10.1186/1472-684X-7-11.
- Lamba S, DeSandre PL, Todd KH, Bryant EN, Chan GK, Grudzen CR, Weissman DE, Quest TE; Improving Palliative Care in Emergency Medicine Board. Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration. J Emerg Med. 2014;46(2):264-70. Available from: doi: 10.1016/j.jemermed.2013.08.087.
- Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med. 2013;14(6):633-6. Available from: doi: 10.5811/westjem.2013.5.14674. PMID: 24381685.
- Quest TE. Marco CA. Derse AR. Hospice and palliative medicine: New subspecialty, new opportunities. Ann Emerg Med. 2009;54:94–102;
- Temel JS. Greer JA. Muzikansky A. Gallagher ER. Admane S. Jackson VA. Dahlin CM. Blinderman CD. Jacobsen J. Pirl WF. Billings JA. Lynch TJ. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733–742;
- Institute of Medicine (US) and National Research Council (US) National Cancer Policy Board. Improving Palliative Care for Cancer. Foley KM, Gelband H, editors. Washington (DC): National Academies Press (US); 2001. PMID: 25057564.
- Grudzen CR, Stone SC, Morrison RS. The palliative care model for emergency department patients with advanced illness. J Palliat Med. 2011;14(8):945-50. Available from: doi: 10.1089/jpm.2011.0011.
- Lamba S, Schmidt TA, Chan GK, Todd KH, Grudzen CR, Weissman DE, Quest TE; IPAL-EM Board. Integrating palliative care in the out-of-hospital setting: four things to jump-start an EMS-palliative care initiative. Prehosp Emerg Care. 2013;17(4):511-20. Available from: doi: 10.3109/10903127.2013.811566