Portal de Periódicos da CAPES

Practically speaking: Emergency medicine and the palliative care movement

2012; Wiley; Volume: 24; Issue: 1 Linguagem: Inglês

10.1111/j.1742-6723.2011.01531.x

1742-6731

Knox H. Todd,

Family and Patient Care in Intensive Care Units

See also pp. 102–104 Daily experience in the ED suggests that patients suffering from chronic life-limiting illnesses are all too often caught in a revolving door of emergency care that wastes resources and fails to properly address their stage of disease and goals of care. With regularity, these patients cycle from acute episode to acute episode – from the ED to a hospital bed and home again – without being offered palliative care services that could ease distressing symptoms, improve coordination of services and provide caregiver relief. Critical decisions made in the ED can determine the subsequent intensity and trajectory of medical treatments for life-limiting illnesses, which include appropriate levels of hospital care (including intensive care unit utilization). Thus, the ED is a crucial setting for identifying unmet palliative care needs and initiating end-of-life discussions with patients, families and primary care physicians to ensure appropriate care. Traditionally, specialty-level palliative care services receive consults and referrals long after hospital admission, and often in the last few days of a patient's life. Emergency physicians in the USA and Australia have an important opportunity and responsibility to intervene in the debilitating downward spiral of repeated acute care episodes among frail ED patients. With an increased emphasis on ED-based palliative care, patients who can benefit from palliative care services will be identified more frequently and earlier in the course of their illness.1 The palliative care service at Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia, USA was an early innovator in this area, making a concerted effort to provide palliative care services to the ED. As a result of their efforts, the VCU ED began admitting significant and increasing numbers of patients directly to the palliative care unit rather than to general medical wards or intensive care units. In 2004, the Wall Street Journal highlighted the dramatic decreases in cost of care resulting from their avoidance of inappropriate intensive care utilization and reductions in excessive laboratory testing and imaging.2 By 2006, the number of academic emergency physicians in the USA with an active interest in palliative care became sufficient to justify our first developmental meeting. This workshop, entitled Establishing a Palliative Care Research and Training Agenda for Emergency Medicine, was held in San Francisco at the 2006 annual meeting of the Society for Academic Emergency Medicine. Dr J Brian Cassel, a member of the Palliative Care Leadership Center at VCU, attended and was an influential participant in this meeting. As noted in the article by Lukin et al. in this issue, the American Board of Emergency Medicine in 2006 supported the new subspecialty of hospice and palliative medicine, thereby including emergency medicine training as a recognized pathway to board certification in palliative medicine.3 Since that time, a new cadre of emergency physicians, with additional specialty training in palliative medicine, has become board-certified in both specialties. Many of these dual-boarded specialists have joined our academic training programmes and have become a driving force to establish higher levels of quality in both generalist and specialty-level palliative care in our EDs. A prudent first step for those considering ED-based palliative care initiatives is to anticipate the likely barriers they might encounter in such an effort. In our work to promote palliative care, we have encountered three barriers (among many others) that deserve mention. One of the more important barriers is our colleagues' perception that ED patients' unmet palliative care needs are being adequately met in other clinical settings. In formative work, conducted in 2007 at Beth Israel Medical Center in New York, we addressed this perception by conducting an observational screening study for ED patients with chronic life-limiting illnesses, including advanced dementia, severe congestive heart failure or chronic obstructive pulmonary disease, or advanced malignancy, and the presence of unmet palliative care needs, such as high levels of symptom distress, extremely poor functional status or high levels of caregiver burden. Of 62 patients thus identified, all with a history of multiple ED visits and unambiguous indications for palliative care intervention, none had received such services. Twenty-two of these patients (35%) died within 60 days of their index ED visit.4 Clearly, our existing patterns of care and referral were inadequate to meet our patients' needs. Second, before asking, it is important to consider whether sufficient resources exist to answer the question. ED-based screening efforts will create new demands for services and have the potential to overwhelm existing palliative care resources. The failure of specialty-level palliative care providers to meet this ED demand might dampen enthusiasm for such efforts. As a caution, by the end of our 2007 New York effort, fully half of our hospital's palliative care consultation requests originated from the ED.5 Opening channels of communication to our palliative care colleagues before our screening campaign helped lend credibility to our effort and facilitated our identification of existing palliative care resources, such as community-based assistance programmes, which might have otherwise been unrecognized and underutilized. Innovators should take steps to foster inclusive relationships between emergency nursing, emergency medicine and palliative care services, involving all stakeholders from the beginning in order to break down boundaries that might exist between departments. Third, the challenge of providing palliative care interventions in our overcrowded EDs must be considered. ED demand in the USA has grown tremendously over time and many of our EDs are routinely overcrowded, and occasionally, chaotic. Despite these challenges, the specialty of emergency medicine has prospered in the current health-care environment. The majority of hospital admissions flow through the ED and emergency medicine's increasing sphere of influence presents an opportunity to alter the current priorities of our health-care systems, particularly with regard to promoting palliative care access. We are problem-solvers, and should position our efforts as welcome solutions to obvious deficiencies, rather than unnecessary burdens imposed on our day-to-day practice. To meet these challenges, we must identify ED palliative care champions: they are often non-physicians. Many of these supporters are serving in hospital and health-care leadership positions. Some will have individual life experiences with family members or loved ones that cause them to question ‘heroic’ interventions performed on obviously dying patients. Nurses and social workers can be valuable allies and indeed, leaders in this effort. These health-care providers are often the first to recognize that patients' unmet palliative care needs remain unaddressed by existing care mechanisms. During our work among New York City hospitals, nurse-initiated palliative consultations became the norm within one ED, and in another, emergency medicine social workers initiated the process. To support those who plan ED-based palliative care quality improvement initiatives, a number of experts in emergency medicine, palliative care, emergency nursing and social work were brought together in 2011 by the Center to Advance Palliative Care to develop The Improving Palliative Care in Emergency Medicine (IPAL) Project. The IPAL Project provides an online resource to support best practices in emergency medicine palliative care and interested readers are directed to the project website (http://www.capc.org/ipal/). A catalogue of tools, including background documents on the need for ED-based palliative care, presentations to help make the case to hospital leadership, needs assessment instruments, lists of key operational, clinical and satisfaction metrics, and screening instruments, are available for your use. We even include a plan for accomplishing ‘four things’ in one week to jump-start the process. We welcome your feedback on how these tools are useful to you and how they might be improved. Our plan is to continually update this resource based on our users' input. A variety of forces bode well for improvements in ED end-of-life care, including changes in population demographics, unsustainable health-care expenditure, and the development of palliative medicine and hospice specialties. Emergency medicine adds a strategically important voice to the growing chorus calling for improvements in end-of-life care. As is often the case, a small group of individuals who are both interested and committed, can be the key to change in our health-care system. The next move is yours. None declared.