Adults with chronic illnesses visit the emergency department (ED) several times in their last months of life, with many of them dying in the ED.
Early palliative care (PC) engagement in the ED has the potential to impact the therapeutic decisions.
Indications for PC consultation in the ED
• Difficult-to-manage pain or other symptoms
• Symptom management for an actively dying patient
• Rapid consensus for goals of care or complex decision making
• Clarify provisions in an advance directive
• Withdrawal of non-beneficial treatments
• Bereavement support
• Care coordination
The PC team should proactively discuss the consultation processes with the ED leadership to clarify when and how PC team members will be available for an ED consult, by phone or person.
Suggested consultation protocol
¿What is needed from the ED team? Orders for symptom control, dialogue with family? Certain issues, such as symptom control, may be initiated or handled over the phone whereas more complex issues such as urgent goals of care discussions may need in-person support.
• Emergent (clinical status unstable; decision to intubate, decision to withdraw ventilator)
• Urgent (patient relatively stable; help needed for disposition planning)
• Routine (patient is being admitted, has non-urgent needs, can be seen as inpatient).
¿Which PC team member is best suited to address the ED query?
- Discuss personally the findings and/or recommendations with the appropriate member of the ED staff before initiating any definitive patient/family communication or intervention.
- Gather additional data needed to offer quality care
- Be explicit in disposition and treatment directions; make sure your recommendations are achievable to implement and fit the ED policies and protocols.
- Teach with tact providing a protocol for pain, or an opioid equivalency table.
- Communicate the established plan of care to the patient, family, ED clinician and the provider for the patient’s next place of disposition.
See reference for more information.
Adapted from Lamba S et al. Palliative care consultation in the emergency department. Palliative Care Network of Wisconsin. Fast facts and concepts #298. Internet. Accessed on January 5, 2019.