Adults with chronic illnesses visit the emergency department (ED) several times in their last months of life. Hence, the ED serves many patients with unmet palliative care needs. Initial care decisions made in the ED also set the future hospital trajectory of care — early palliative care (PC) engagement in the ED has the potential to have an impact on these 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 (e.g., intubation decision) or complex decision-making
• Clarify provisions in an advance directive
• Withdrawal of non-beneficial treatments
• Bereavement support (e.g., after sudden deaths in victims of trauma or death of a child)
• Challenging dispositions requiring care coordination
ED providers often expect in-person consultation time within 30-60 minutes. PC programs should proactively discuss the consultation processes with the ED leadership to clarify when and how palliative care team members will be available for an ED consult, by phone, or in person.
To best serve the ED staff, PC team members are encouraged to follow these principles of consultation etiquette.
1. Determine what is needed from the ED team. Is it orders for symptom control, dialogue with family, guidance with disposition planning? Certain issues, such as symptom control, may be initiated or handled over the phone whereas more complex issues may need in-person support.
2. Establish urgency.
• Emergent (e.g., clinical status unstable; decision to intubate, decision to withdraw ventilator)
• Urgent (e.g., patient relatively stable; help needed for disposition planning)
• Routine (e.g., patient is being admitted, has non-urgent needs, can be seen as inpatient)
3. Determine which PC member is best suited to address the ED query; initiate telephone support as soon as feasible.
4. Discuss in-person your findings and/or recommendations with the appropriate member of the ED staff before initiating a patient/family communication or intervention.
5. A verbal 2- to 4-minute summary of recommendations immediately after the consult is useful.
6. Disposition and treatment directions must be explicit (e.g., “begin with morphine 5 mg IV and repeat every 15 minutes until pain is less than 5”). Recommendations must be feasible to implement and fit the ED policies and protocols. Clarify who will be contacting other stakeholders (home care, caregivers, etc) and what messages will be communicated.
7. Provide continuity by communicating the established plan of care to the patient, family, ED clinician, and the provider for the patient’s next place of disposition.
PC team members are encouraged to learn about ED culture and develop positive relationships by joining in ED care rounds, serving as educational resources, and working collaboratively on institutional protocols.
See reference for more information. Adapted from Lamba A, Quest TE, Weissman DE. Palliative care in the emergency department. Palliative Care Network of Wisconsin. Fast facts and concepts #298. Internet. Accessed on December 5, 2019.