The HFMA Leadership article highlighted the opportunity to deploy palliative care in the emergency department (ED) to improve patient outcomes and value.
“The Choosing Wisely campaign from the American College of Emergency Physicians (ACEP) includes this recommendation: “Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.”
Palliative care relieves symptoms, such as pain, anxiety, and breathing difficulty, for patients who have chronic or incurable diseases while hospice care is palliative care for patients who are approaching the end of life.
ACEP’s recommendation is based on research showing that ED referrals to hospice and palliative care services can result in improved quality and duration of life for some patients, but most EDs do not provide access to palliative services.
“We identified that many patients near the end of life came into the ED and had a very difficult interaction,” says Robert Femia, MD, chair of Langone Health’s Department of Emergency Medicine. “Patients were getting admitted to the hospital without a true understanding of their preferred goals of care, which oftentimes centered on pain control, symptom management, and relieving caregiver stress. And there was organizational concern about patients not getting the right care in the right setting.”
Clinicians at the Ronald O. Perelman Center for Emergency Services at NYU Langone Health compared outcomes for ED patients who received a palliative care consult initiated by the ED physician with those for patients who were admitted to the hospital and received a palliative care consult during their admission, according to the article, “Cost Savings and Palliative Care Referrals from the Emergency Department,” in the September/October issue of Physician Leadership Journal. Their findings: For palliative care consults that were initiated in the ED, patients’ length-of-stay was, on average, 45 percent shorter than it was for patients whose consults came later. And the variable direct costs for those patients were reduced by between 50 percent and 70 percent, depending on whether the patients were admitted to the hospital’s hospice unit or another destination. The cost savings likely came from decreases in testing, futile interventions, and intensive care unit utilization, according to Femia.
“Meanwhile, patients were involved in shared decision-making and were spared unwanted treatments while clinicians focused on alleviating their pain and other distress,” Femia says.
I believe that one of the reasons we haven’t seen better results from the various Advanced Payment Models the U.S. healthcare system is experimenting with is we’ve failed to engage the patient, in a meaningful way, in decisions about their care. In many instances, patients who understand all their treatment options opt for far more conservative care than what providers would order. When patients are meaningfully involved in care decisions, it not only produces better outcomes but lowers the total cost of care while respecting patients’ wishes.
In the instance of palliative care and end-of-life decision-making, Femia’s statements above indicate patients benefit from not receiving aggressive care that extends life without adding quality (and in some cases degrades quality). Other studies indicate it improves both the clinician- and family-member experience of care.
An article, “Patient Engagement: A Missing Piece to the Value Puzzle,” I wrote a couple of years ago provides examples of organizations that I believe are doing this right. The article also illustrates the potential upside from better engaging patients in care decisions.