PALLIATIVE CARE
Nuances of ED-Based Palliative Medicine: Unexpected Challenges and Benefits
SAEM PULSE | MAY-JUNE 2023
By Caroline Meehan, MD, and Leah McDonald, MD
50
Given the proven benefit of palliative care — including improved quality of life and decreased health care costs — there is an increased interest in moving this care upstream and into the emergency department (ED). Accordingly, there are a growing number of palliative medicine programs embedded within the ED, and this treatment model has become a new topic of research and program development. At The Miriam Hospital (A Lifespan community hospital and teaching affiliate of Brown University, located Providence, Rhode Island), we recently initiated such a program led by a dual-trained ED and palliative medicine physician. The following vignettes highlight some of the nuances and challenges of practicing palliative medicine within the ED setting.
Rapid Prognostication and Medical Recommendations With Limited Information
Scenario: A 72-year-old female with history of metastatic lung cancer not actively undergoing cancer-directed therapy presents to the ED with altered mental status. The family reports that the patient has had an abrupt decline over the last week. The patient is no longer taking anything by mouth, is minimally responsive, and dependent for all activities of daily living. Laboratory workup and imaging have not yet resulted. The family inquires, “how much time does she have?” Moreso than some other disciplines, ED providers must inherently be comfortable with making decisions with an element of uncertainty. Each shift, we must decide, with limited
information, whether someone is safe to be discharged or requires admission to the hospital. Palliative care in this setting involves a similar element of uncertainty. A key component of training for palliative physicians is learning how to prognosticate. In the inpatient setting, prognostication is often based on days of hospital data on a patient’s health status and disease trajectory. When we have palliative discussions in the ED, however, prognostication occurs with extremely limited hospital-based data, as patients are often early in their workups. Instead of guidance based on a prolonged hospital course, prognosis is instead based on recent status prior to hospital presentation which may be difficult to assess, particularly in patients with cognitive impairments or instances when family is not available to provide collateral information.