In the controlled chaos of an hospital emergency department, ensuring that patients are pain-free and can make informed choices about their care often takes a back seat to assessing and stabilizing them and moving them through the system as fast as possible. But now some experts say that providing palliative care – which focuses on patients' quality-of-life issues – can and should be a priority in emergency departments, and they're putting together a program to help hospitals better address those issues.
"A decade ago, we thought of the emergency department as a way station," says Tammie Quest, an associate professor of emergency medicine at Emory University School of Medicine who is also board-certified in hospice and palliative medicine. "Now we're recognizing what can be done to identify patient needs there, and help to initiate what can be done in the hospital or once the patient leaves the hospital."
Under the sponsorship of the Center to Advance Palliative Care, an advocacy organization, Quest is heading up the development of a program that will provide hospitals with online tools and guidelines, identify best practices and link doctors and others with experts to help integrate palliative care into their emergency departments.
Many of the patients who come to the emergency department are suffering from flare-ups of serious illnesses or have suffered a grievous injury and are faced with unexpected decisions that can be life-altering. These are exactly the types of patients palliative care aims to help, say experts.
With training, emergency department staff members can enhance their skills in pain and symptom management, a challenge in patients with complex medical problems, says Quest. They can also improve their communication skills so that they are more empathetic when giving bad news to a patient or relative whom they may have just met, for example, or can help patients quickly develop a plan for care that meets their needs.
Another key to success is incorporating systemic changes, such as checklists, that make discussing patients' wishes – Do they want to be put on a ventilator, if necessary, or be admitted to intensive care? Have they completed end-of-life planning documents? – as routine as checking a patient's airway, breathing and circulation.
"These discussions just aren't happening" right now, says David Weissman, an oncologist and professor emeritus at the Medical College of Wisconsin in Milwaukee, who is consulting on the project. Weissman estimates that fewer than 50 emergency departments are focused on incorporating palliative-care principles.
Palliative care grew out of the hospice movement, which emerged in the 1970s. Today, patients with fewer than six months to live have access to a wide array of supportive services to manage their pain and other symptoms and provide counseling and decision-making help for themselves and family members.
But clinicians and patient advocates have come to realize that other patients – who weren't dying but had serious, chronic or life-limiting illnesses – also needed help managing their pain, coordinating their medical care, assessing their options and addressing their fears, as did their families. That launched the palliative-care movement.
Sixty-three percent of hospitals with more than 50 beds have palliative-care programs in place, up from just 30 percent a decade ago, according to the Center to Advance Palliative Care. In addition to improving patients' quality of life, palliative care makes sound financial sense: A 2008 study published in the Archives of Internal Medicine found that patients who received palliative-care services cost hospitals between $1,696 and $4,908 less per admission.
Starting in September, the Joint Commission, an organization that sets hospital standards and monitors their performance, will begin offering voluntary certification for hospital inpatient palliative-care programs. This may improve insurance coverage of the programs, the cost of which is currently borne by hospitals to a large extent.
Typically, palliative care at hospitals is provided by a specially trained team, often consisting of a doctor, nurse, social worker and chaplain. Rather than try to shoehorn palliative-care teams into the emergency department, however, the new program aims to educate staff and change systems throughout the emergency department, says Quest. The hospital's specialized palliative-care teams would be called in for only the toughest cases.
Garrett Chan was working in the emergency department at Stanford Hospital & Clinics in Palo Alto, Calif., one afternoon when an elderly woman was brought in. It was her 91st birthday, and she had blacked out at her birthday party and taken a fall, fracturing her back.
Chan, a nurse who has a supervisory role in the department and has been incorporating palliative-care principles there, could tell that the woman was upset that she was missing her party. "I knew it was having a negative effect on her health," says Chan. He called the dietary department of the hospital, which decorated a cake with a "Happy Birthday" message.
The cake put a smile on her face, says Chan, at a time when she was dealing with pain and discomfort and facing uncertainty about what had caused her to black out. "It's some of these small interventions," says Chan, "that you might not think are significant, but they have a big effect on psychological and emotional well-being."