Although implementing palliative care processes in the ED is challenging initially, such care can reduce avoidable costs and unnecessary suffering.
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 (ED) for patients likely to benefit.”
Palliative care relieves symptoms—pain, anxiety, breathing difficulty, and others—for patients who have chronic or incurable diseases (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.
Indeed, as recently as five years ago, most emergency physicians were unfamiliar with palliative care, says Mark Rosenberg, DO (pictured at right), chair of emergency medicine at St. Joseph’s Healthcare System in Paterson, N.J.
“Since that time, I think the majority of emergency physicians have come to know what it is, but it’s a long way off before the 4,000 emergency departments across the country have a palliative initiative that meets the Choosing Wisely campaign,” he says.
However, EDs that provide palliative care consults are seeing value in their initiatives. 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. (Femia, R., et al., “Cost Savings and Palliative Care Referrals from the Emergency Department,” Physician Leadership Journal, September/October 2016.)
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, says Robert Femia, MD (pictured at right), chair of NYU Langone Health’s Department of Emergency Medicine. Meanwhile, patients were involved in shared decision making and were spared unwanted treatments while clinicians focused on alleviating their pain and other distress.
“If you start the ball rolling in the ED instead of waiting until the patients get upstairs, all sorts of good things happen,” he says.
Challenges to Palliative Care in the ED
Femia’s department introduced palliative care services after a review of opportunities to improve the patient experience.
“We identified that many patients near the end of life came into the ED and had a very difficult interaction,” he says. “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.”
A work group of ED nurses, ED physicians, and a social worker with palliative care experience convened to examine how care for these patients could be improved. They identified several cultural barriers:
- ED staff thought they needed permission from a patient’s primary care provider to discuss palliative care with patients and their family members.
- Because treatment decisions were physician-driven, nurses did not feel empowered to advocate that palliative care would be a good option for certain patients.
- Emergency physicians, most of whom were not trained to discuss palliative care with patients, thought the topic was better introduced by an oncologist or primary care physician.
Palliative Care in Practice
Femia’s work group started clearing away the barriers and creating a culture that proactively offers palliative care to patients who would benefit from it. The goal was to increase the number of patients who receive a palliative care consult, and the approach was to empower ED staff to take action.
“We created a process where a nurse or social worker could collaborate with the ED physician and initiate the consult by contacting the palliative care team,” Femia says.
In some cases, the ED physician engages the patient and family members in a discussion about goals of care and what palliative care offers. If the ED physician is uncomfortable with the topic, a member of the hospital’s palliative care team is called to the ED to start the conversation.
In 2014, palliative care referrals were initiated in the ED for 240 ED patients. A small subset was referred for direct hospice placement, but the majority were admitted to the hospital with palliative care identified as the treatment plan. That approach avoids unnecessary tests and specialty consults that increase length of stay and are not aligned with patient and family wishes.
“They have much shorter lengths of stay and greater patient satisfaction,” Femia says.
At St. Joseph’s Healthcare, three emergency physicians are board-certified in palliative medicine. “And I have a whole team of nurse champions who can help identify patients who could benefit from palliative care,” Rosenberg says.
The nurses, as well as paramedics and other members of the care team, are trained to use a single question as a screening tool: “Would you be surprised if the patient died during this admission?”
If the answer is no,a clinician trained in palliative care initiates a discussion with the patient and his or her family members to identify goals of care.
“We have many cases in which patients who would have been admitted to the hospital go right to hospice and patients who would have been admitted to the intensive care unit now go to the general medical floor,” Rosenberg says. “We do know that the cost of medical care at end of life has decreased drastically because of these conversations with the patient and the family.”
Even hospitals that do not have a palliative care team to support an ED-led initiative can comply with ACEP’s Choosing Wisely recommendation, Rosenberg says. Relieving patients’ suffering is every clinician’s goal, so ED staff should have the information and training needed to offer the services that are most appropriate for their patients.
Rosenberg, a member of ACEP’s board of directors, recommends that every ED identify the palliative and hospice resources that are available either in the hospital or in the community.
“They should keep that list in the emergency department,” he says. “And the nurses and the medical staff should all be trained in identifying people who are likely to benefit from hospice and palliative care, and they should not delay their referral to those organizations that could help them.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article: Robert Femia, MD, MBA, chair, Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York City; Mark Rosenberg, DO, MBA, chair, Emergency Medicine, and chief innovation officer, St. Joseph’s Healthcare System, Paterson, N.J.