Does Palliative Care Have a Future in the Emergency Department? Discussions With Attending Emergency Physicians

Abstract

Context Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams. Objectives To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED. Methods Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews. Results Twenty emergency physicians participated (mean age 41 years, range 31–61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicined—to provide stabilization of acute medical emergencies—was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician’s responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family. Conclusion Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

Thoughts of Emergency Physicians about Palliative Care: Evaluation of Awareness

“…Having interruption in patient follow-up, lack of trust as there is not long-term relationship, and the limited time allocated to each patient are reported as the main titles of the determined problems. Similar to our study, unnecessary and redundant examination of the PC patients in ED has been detected as a problem; it was asserted that the patients are consulted to PC teams early in ED and that evaluation by PC teams can solve this problem (16).…”

Using Experience-based Co-design with older patients, their families and staff to improve palliative care experiences in the Emergency Department: A reflective critique on the process and outcomes

“…To date the majority of ED-based palliative care research has focused on broad staff experiences rather than with older people specifically (Beckstrand et al, 2012, Grudzen et al, 2012a, Grudzen et al, 2012b. Figures 2 and 4 in particular highlighted the challenges facing ED when confronted with a patient group whose needs sit beyond the traditional ED group.…”

“…This is despite evidence that patient involvement and collaboration is more likely to meet the specific needs of patients, be more reliable and more likely to be implemented in practice (NICE, 2015, Staley et al, 2014. There is limited exploration of the needs and experiences of patients and families as well as ED staff to guide and inform such quality improvement (QI) efforts (Beckstrand et al, 2008, Grudzen et al, 2012a, Smith et al, 2010a, particularly in the UK (Bailey et al, 2011a, Bailey et al, 2011b. In this specific setting, careful consideration is needed to identify, understand and explore the experiences of participants, facilitate joint (patient, family and staff) ownership of the change process and implement a QI intervention.…”

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

“…78 Two key issues cited by ED providers as barriers to PC consultation were absence of 24-hour availability and having incomplete patient information available during a fast-paced ED encounter. To help address these concerns, we made two key provisions in the construction of the screening tool.…”

“…53,78 While it is true that an ED clinician cannot perform a comprehensive PC assessment for a patient based solely on a single clinical encounter in the ED, screening based on easily identifiable attributes of advanced disease states is likely feasible with prompting and cognitive cues. Therefore, we reviewed articles regarding disease-specific thresholds for PC to include appropriate cues for ED providers to sufficiently identify advanced disease states.…”