You have probably heard the term “palliative medicine” a lot lately. At least I hope you have! But what does this type of medicine have to do with the Emergency Department?
Let’s start with some basic questions…How often do you ask yourself :
- Why am I doing this tube/line/CPR/futile procedure on the poor person who will not get any benefit, and most likely get worse?”
- How many patients do you see per week that you do a full work-up and management that you would NOT be surprised if they died within the next 6 months?
- How often are you coding a patient that has obviously been declining for a while with a chronic/terminal condition such as CHF/COPD/dementia and the family has no conception of what is happening?
If you identify with any of these scenarios then read on…
Just as many serious public health questions have ended up on our doorstep (violence, the uninsured, addiction, HIV, and chronic pain) managing terminal illness has become our problem as well. A large group of patients and families really need help, and they are not getting it anywhere else.
ACEP chose initiating palliative care as one of our five contributions to The Choosing Wisely Campaign in response to these concerns. But how do we make this operational? Where can we start? The field of Palliative Medicine is huge but emergency physicians can have a big impact!
We have a big impact because what we do in the ED becomes, for better or worse, the treatment track upon admission. It is essential that we initiate treatment in-line with a patient’s goals. With a bit of training we ED docs can become great at helping patients voice their goals and in turn become leaders for other specialties.
We must shift our focus from “getting the DNR” to getting the patient’s “goals of care”. In order to do this well, we must get away from dichotomous questions like “do you want us to do everything? or nothing?” We must get a sense of the patient and their family. A very useful order of questions is as follows:
- What is your understanding of your illness?
- How much information do you want to be told?
- If your health situation worsens, what are your most important goals?
- What are your biggest fears and worries about the future?
- What are you willing to trade off for more time?
If you get stuck, a great statement is the “I hope” statement. “Of course we hope that you will continue to improve, but as we hope for the best we also need to prepare for the worst.” The ideal is to synthesize the medical science with the patient’s goals, THEN make recommendations.
These patients and their families come to the ED with acute symptoms due to a crisis point in the trajectory of their illness. We need to become experts at palliative symptom management (have you ever considered Haldol for intractable vomiting?). If we can make people comfortable, we have a shot at having meaningful discussions with them and their families about the next steps.
Often I find that talking about symptoms – starting with pain, nausea, vomiting, then getting into deeper issues (fears and anxieties, depression, appetite, weight loss) restores hope in patients and families. This helps build trust when you make recommendations for treatment and disposition.
An important tool that has been legally and officially adopted in the State of NJ is the POLST Form. These Forms are transferable and legally binding across all health care settings (as opposed to DNRs). While generally meant to be filled out by the patient and his/her primary care provider, any physician can help a patient enact one.
Obviously there is still much work to be done outside of emergency medicine to create the programs and systems needed to properly care for people at the end of their lives. However, we see these patient’s everyday and can be the ones that:
- Identify these patients
- Assist the patient and family in clarifying their goals
- Modify the immediate treatment plan based on those goals
- Facilitate a hand-off to a more comprehensive services:
- Private medical doctors
- Palliative Care services
- Hospice (inpatient and outpatient)
If you are interested in learning more about palliative medicine please visit us at: ACEP Palliative Medicine Section and consider joining!
Kate Aberger MD is board certified in Emergency Medicine and Hospice and Palliative Medicine. She practices at St. Joseph’s Regional Medical Center in Paterson and is the incoming President of ACEP’s Palliative Medicine Section.