Palliative Care Is No Longer a Stranger to Emergency Medicine

LAS VEGAS – Palliative care is increasingly recognized as having an important role to play in emergency medicine, according to Dr. Knox H. Todd.

Palliative care is growing exponentially overall, and the American Board of Emergency Medicine has joined nine other specialty boards in supporting its approval as an official subspecialty, meaning that emergency physicians can now pursue certification, he said at the annual meeting of the American College of Emergency Physicians.

“We can’t give clear numbers on [how many] emergency physicians are now board certified in palliative care, but I think it’s probably around 30 or 40,” said Dr. Todd, who is director of the Pain and Emergency Medicine Institute at Beth Israel Medical Center and a professor of emergency medicine at Albert Einstein College of Medicine, both in New York.

Integrating palliative care with emergency medicine makes sense for a lot of reasons, he said. “One of the most obvious is that a lot of people die in the emergency department,” with some 379,000 deaths occurring nationally in EDs in 2000 alone.

Furthermore, emergency medical services often are activated for patients with terminal illnesses. And not only is the ED the entry point for most adult patients who die in the hospital, but it also often functions as a “revolving door” for patients whose health is in a downward spiral (N. Engl. J. Med. 2009;360:1418-28).

Dr. Todd noted that a set of core palliative care skills recently proposed for emergency physicians range from the fairly routine, such as estimating prognosis, to the much more difficult, such as withdrawing or withholding nonbeneficial treatment (Ann. Emerg. Med. 2009;54:94-102).

Research on palliative care specifically in the emergency medicine setting is still scant, he said. But “many emergency physicians who practice palliative care now and are pursuing palliative care fellowships are becoming very active in this field and will lead this field from here on.”

Dr. Todd described a program undertaken in his ED in 2007 to better identify patients with unmet palliative care needs, noting that previously, there had been very little interaction between emergency medicine and palliative care and hospice services.

The goals were to screen incoming patients for unmet palliative care needs; to provide appropriate care, reducing symptom burden and decreasing caregiver distress; to refer patients to palliative care and hospice; and to assess financial sustainability of the program using a social worker.

The screening protocol aimed to identify mainly adults aged 65 years or older who had chronic life-limiting illnesses with at least moderate functional limitations plus any of several factors signaling severe disease impact (increasing loss of activities of daily living, high symptom distress, poor functional status, or high caregiver burden).

During a 3-month screening-only period, 864 patients were screened, of whom 5% had unmet palliative care needs and an additional 2% had both unmet palliative care and hospice needs, Dr. Todd reported. After 7 months, half of these 62 patients had died.

“These were patients who had been in our emergency department three or four times in the last 6 months but never even had the talk about the possibility of involving palliative care,” he commented. “They rotated through our internal medicine service generally or perhaps the oncology service.”

During its 8-month implementation phase, the program ran into some barriers. For example, in 49% of cases in which eligible patients did not get a palliative care consultation, the patient’s primary care physician had objected to the consultation. But objections also came from the emergency physicians (25% of cases), the patient or family (15%), social workers (8%), and house staff (3%).

“Part of our primary care issue was, are we going to offend the primary caregiver by introducing a palliative care intervention in a patient with whom he or she has had a longstanding connection,” he acknowledged.

The team revised the program and conducted outreach, implementing measures to address the concerns of other providers and to promote and simplify the referral for palliative care consultations.

“Our story does have, I think, limited success,” Dr. Todd said. At the end of the year, the hospital’s total number of palliative care consultations per quarter had increased by 33%. Moreover, half were now initiated from the ED, compared with none at the start of the program.

However, the average length of hospital stay for screened patients before and after intervention was largely unaffected, and results suggested that the program would not be financially sustainable using a social worker.

Also, about 70% of emergency physicians surveyed at the end of the program identified the social worker as the best professional to implement palliative care interventions in the ED. “So we provided a service, yet we freed our emergency physicians and emergency nurses from thinking about this, which is an unintended negative consequence of this study,” Dr. Todd commented.

A second project, undertaken in 2009-2010 and called the Emergency Department Palliative Care Champions (EDPCC) Pilot Project, involved outreach from his center to three New York City–area hospitals.

The center served as an external resource that fostered ED palliative care initiatives by supporting ED palliative care champions who disseminated education and conducted rapid quality-improvement projects in their departments.

Across the three hospitals – St. Vincent’s Medical Center, Mount Sinai Medical Center, and Kings Highway Division – the project ultimately involved 20 ED champions and 236 ED staff members, at a total program cost of about $125,500.

St. Vincent’s undertook nurse-initiated screening for unmet palliative care needs, training more than 40 nurse screeners and screening 22 patients in a 6-month period, according to Dr. Todd.

Mount Sinai conducted a quality audit of care for imminently dying patients, interviewing staff after patients died to determine what could have been done differently. This led to procedural changes in the ED, such as designating a space for grieving families.

Finally, Kings Highway Division undertook an initiative to improve implementation of advance directives. As a result, the proportion of patients for whom advance directive status was obtained increased from essentially zero to nearly 100%.

Overall, the EDPCC project has proven feasible and acceptable, and has potential for replication and dissemination, Dr. Todd contended. If funding is obtained, it will be expanded to the entire city.

He noted that emergency physicians are likely to have increasing access to palliative care specialists, as the percentage of larger hospitals having palliative care programs has increased to roughly 40%.

“This whole area of working hand in hand with our palliative care colleagues is one that I would like to encourage,” he concluded.

LAS VEGAS – Palliative care is increasingly recognized as having an important role to play in emergency medicine, according to Dr. Knox H. Todd.

Palliative care is growing exponentially overall, and the American Board of Emergency Medicine has joined nine other specialty boards in supporting its approval as an official subspecialty, meaning that emergency physicians can now pursue certification, he said at the annual meeting of the American College of Emergency Physicians.

“We can’t give clear numbers on [how many] emergency physicians are now board certified in palliative care, but I think it’s probably around 30 or 40,” said Dr. Todd, who is director of the Pain and Emergency Medicine Institute at Beth Israel Medical Center and a professor of emergency medicine at Albert Einstein College of Medicine, both in New York.

Integrating palliative care with emergency medicine makes sense for a lot of reasons, he said. “One of the most obvious is that a lot of people die in the emergency department,” with some 379,000 deaths occurring nationally in EDs in 2000 alone.

Furthermore, emergency medical services often are activated for patients with terminal illnesses. And not only is the ED the entry point for most adult patients who die in the hospital, but it also often functions as a “revolving door” for patients whose health is in a downward spiral (N. Engl. J. Med. 2009;360:1418-28).

Dr. Todd noted that a set of core palliative care skills recently proposed for emergency physicians range from the fairly routine, such as estimating prognosis, to the much more difficult, such as withdrawing or withholding nonbeneficial treatment (Ann. Emerg. Med. 2009;54:94-102).

Research on palliative care specifically in the emergency medicine setting is still scant, he said. But “many emergency physicians who practice palliative care now and are pursuing palliative care fellowships are becoming very active in this field and will lead this field from here on.”

Dr. Todd described a program undertaken in his ED in 2007 to better identify patients with unmet palliative care needs, noting that previously, there had been very little interaction between emergency medicine and palliative care and hospice services.

The goals were to screen incoming patients for unmet palliative care needs; to provide appropriate care, reducing symptom burden and decreasing caregiver distress; to refer patients to palliative care and hospice; and to assess financial sustainability of the program using a social worker.

The screening protocol aimed to identify mainly adults aged 65 years or older who had chronic life-limiting illnesses with at least moderate functional limitations plus any of several factors signaling severe disease impact (increasing loss of activities of daily living, high symptom distress, poor functional status, or high caregiver burden).

During a 3-month screening-only period, 864 patients were screened, of whom 5% had unmet palliative care needs and an additional 2% had both unmet palliative care and hospice needs, Dr. Todd reported. After 7 months, half of these 62 patients had died.

“These were patients who had been in our emergency department three or four times in the last 6 months but never even had the talk about the possibility of involving palliative care,” he commented. “They rotated through our internal medicine service generally or perhaps the oncology service.”

During its 8-month implementation phase, the program ran into some barriers. For example, in 49% of cases in which eligible patients did not get a palliative care consultation, the patient’s primary care physician had objected to the consultation. But objections also came from the emergency physicians (25% of cases), the patient or family (15%), social workers (8%), and house staff (3%).

“Part of our primary care issue was, are we going to offend the primary caregiver by introducing a palliative care intervention in a patient with whom he or she has had a longstanding connection,” he acknowledged.

The team revised the program and conducted outreach, implementing measures to address the concerns of other providers and to promote and simplify the referral for palliative care consultations.

“Our story does have, I think, limited success,” Dr. Todd said. At the end of the year, the hospital’s total number of palliative care consultations per quarter had increased by 33%. Moreover, half were now initiated from the ED, compared with none at the start of the program.

However, the average length of hospital stay for screened patients before and after intervention was largely unaffected, and results suggested that the program would not be financially sustainable using a social worker.

Also, about 70% of emergency physicians surveyed at the end of the program identified the social worker as the best professional to implement palliative care interventions in the ED. “So we provided a service, yet we freed our emergency physicians and emergency nurses from thinking about this, which is an unintended negative consequence of this study,” Dr. Todd commented.

A second project, undertaken in 2009-2010 and called the Emergency Department Palliative Care Champions (EDPCC) Pilot Project, involved outreach from his center to three New York City–area hospitals.

The center served as an external resource that fostered ED palliative care initiatives by supporting ED palliative care champions who disseminated education and conducted rapid quality-improvement projects in their departments.

Across the three hospitals – St. Vincent’s Medical Center, Mount Sinai Medical Center, and Kings Highway Division – the project ultimately involved 20 ED champions and 236 ED staff members, at a total program cost of about $125,500.

St. Vincent’s undertook nurse-initiated screening for unmet palliative care needs, training more than 40 nurse screeners and screening 22 patients in a 6-month period, according to Dr. Todd.

Mount Sinai conducted a quality audit of care for imminently dying patients, interviewing staff after patients died to determine what could have been done differently. This led to procedural changes in the ED, such as designating a space for grieving families.

Finally, Kings Highway Division undertook an initiative to improve implementation of advance directives. As a result, the proportion of patients for whom advance directive status was obtained increased from essentially zero to nearly 100%.

Overall, the EDPCC project has proven feasible and acceptable, and has potential for replication and dissemination, Dr. Todd contended. If funding is obtained, it will be expanded to the entire city.

He noted that emergency physicians are likely to have increasing access to palliative care specialists, as the percentage of larger hospitals having palliative care programs has increased to roughly 40%.

“This whole area of working hand in hand with our palliative care colleagues is one that I would like to encourage,” he concluded.

LAS VEGAS – Palliative care is increasingly recognized as having an important role to play in emergency medicine, according to Dr. Knox H. Todd.

Palliative care is growing exponentially overall, and the American Board of Emergency Medicine has joined nine other specialty boards in supporting its approval as an official subspecialty, meaning that emergency physicians can now pursue certification, he said at the annual meeting of the American College of Emergency Physicians.

“We can’t give clear numbers on [how many] emergency physicians are now board certified in palliative care, but I think it’s probably around 30 or 40,” said Dr. Todd, who is director of the Pain and Emergency Medicine Institute at Beth Israel Medical Center and a professor of emergency medicine at Albert Einstein College of Medicine, both in New York.

Integrating palliative care with emergency medicine makes sense for a lot of reasons, he said. “One of the most obvious is that a lot of people die in the emergency department,” with some 379,000 deaths occurring nationally in EDs in 2000 alone.

Furthermore, emergency medical services often are activated for patients with terminal illnesses. And not only is the ED the entry point for most adult patients who die in the hospital, but it also often functions as a “revolving door” for patients whose health is in a downward spiral (N. Engl. J. Med. 2009;360:1418-28).

Dr. Todd noted that a set of core palliative care skills recently proposed for emergency physicians range from the fairly routine, such as estimating prognosis, to the much more difficult, such as withdrawing or withholding nonbeneficial treatment (Ann. Emerg. Med. 2009;54:94-102).

Research on palliative care specifically in the emergency medicine setting is still scant, he said. But “many emergency physicians who practice palliative care now and are pursuing palliative care fellowships are becoming very active in this field and will lead this field from here on.”

Dr. Todd described a program undertaken in his ED in 2007 to better identify patients with unmet palliative care needs, noting that previously, there had been very little interaction between emergency medicine and palliative care and hospice services.

The goals were to screen incoming patients for unmet palliative care needs; to provide appropriate care, reducing symptom burden and decreasing caregiver distress; to refer patients to palliative care and hospice; and to assess financial sustainability of the program using a social worker.

The screening protocol aimed to identify mainly adults aged 65 years or older who had chronic life-limiting illnesses with at least moderate functional limitations plus any of several factors signaling severe disease impact (increasing loss of activities of daily living, high symptom distress, poor functional status, or high caregiver burden).

During a 3-month screening-only period, 864 patients were screened, of whom 5% had unmet palliative care needs and an additional 2% had both unmet palliative care and hospice needs, Dr. Todd reported. After 7 months, half of these 62 patients had died.

“These were patients who had been in our emergency department three or four times in the last 6 months but never even had the talk about the possibility of involving palliative care,” he commented. “They rotated through our internal medicine service generally or perhaps the oncology service.”

During its 8-month implementation phase, the program ran into some barriers. For example, in 49% of cases in which eligible patients did not get a palliative care consultation, the patient’s primary care physician had objected to the consultation. But objections also came from the emergency physicians (25% of cases), the patient or family (15%), social workers (8%), and house staff (3%).

“Part of our primary care issue was, are we going to offend the primary caregiver by introducing a palliative care intervention in a patient with whom he or she has had a longstanding connection,” he acknowledged.

The team revised the program and conducted outreach, implementing measures to address the concerns of other providers and to promote and simplify the referral for palliative care consultations.

“Our story does have, I think, limited success,” Dr. Todd said. At the end of the year, the hospital’s total number of palliative care consultations per quarter had increased by 33%. Moreover, half were now initiated from the ED, compared with none at the start of the program.

However, the average length of hospital stay for screened patients before and after intervention was largely unaffected, and results suggested that the program would not be financially sustainable using a social worker.

Also, about 70% of emergency physicians surveyed at the end of the program identified the social worker as the best professional to implement palliative care interventions in the ED. “So we provided a service, yet we freed our emergency physicians and emergency nurses from thinking about this, which is an unintended negative consequence of this study,” Dr. Todd commented.

A second project, undertaken in 2009-2010 and called the Emergency Department Palliative Care Champions (EDPCC) Pilot Project, involved outreach from his center to three New York City–area hospitals.

The center served as an external resource that fostered ED palliative care initiatives by supporting ED palliative care champions who disseminated education and conducted rapid quality-improvement projects in their departments.

Across the three hospitals – St. Vincent’s Medical Center, Mount Sinai Medical Center, and Kings Highway Division – the project ultimately involved 20 ED champions and 236 ED staff members, at a total program cost of about $125,500.

St. Vincent’s undertook nurse-initiated screening for unmet palliative care needs, training more than 40 nurse screeners and screening 22 patients in a 6-month period, according to Dr. Todd.

Mount Sinai conducted a quality audit of care for imminently dying patients, interviewing staff after patients died to determine what could have been done differently. This led to procedural changes in the ED, such as designating a space for grieving families.

Finally, Kings Highway Division undertook an initiative to improve implementation of advance directives. As a result, the proportion of patients for whom advance directive status was obtained increased from essentially zero to nearly 100%.

Overall, the EDPCC project has proven feasible and acceptable, and has potential for replication and dissemination, Dr. Todd contended. If funding is obtained, it will be expanded to the entire city.

He noted that emergency physicians are likely to have increasing access to palliative care specialists, as the percentage of larger hospitals having palliative care programs has increased to roughly 40%.

“This whole area of working hand in hand with our palliative care colleagues is one that I would like to encourage,” he concluded.