Palliative Care in the Emergency Department

Contributed by:
Jean Kriz, MD – Emergency Medicine/Palliative Care, OSF Saint Anthony Medical Center

Like most emergency physicians, I was drawn to emergency medicine by the opportunity to save lives and stomp out disease. Emergency medicine, by its very nature, makes me a “jack of all trades” and a specialist in resuscitation and stabilization.  Resuscitation and stabilization is what many of us love and do best in the emergency department (ED).  Doing procedures and interventions that save and prolong lives gives us our greatest satisfaction.

During the early years of my career, this was my focus… for all patients. I didn’t question whether or not it was the right thing to do for everyone regardless of their age, diseases or prognosis.  I figured it was my job to “do everything” to save and prolong lives in the ED and let the rest get sorted out in the ICU.

“We Have to Do Better!”

Over the past few years, my feeling about this has changed. Several things have led to this:

• The death of both of my parents
• An 89-year-old patient in the ED who told her family “I just don’t want to do this anymore” after several admissions for congestive heart failure
• Learning about an elderly patient with stage IV metastatic cancer who received CPR several times in the last few days of her life.

All of these reasons made me realize that we have to do better!

Doing Better Means Communication

What does doing better entail? Communication, communication, communication! This is a skill that is not always taught well in our medical training. Learning procedures and learning how to resuscitate and stabilize are given a much higher priority than communication.

Coupled with that is the fact that there is simply not enough time in a busy ED to establish effective communication. The fast pace and endless interruptions make it difficult, if not impossible, to quickly forge the kind of relationship with a patient and his/her family to be effective in assisting with such complex and sensitive decision-making.

These discussions need to start in the ED whenever possible because they determine the trajectory of the patient’s inpatient course. It is the ideal place to initiate discussions about goals of care before procedures such as intubation have been done that are difficult to undo, not only physically but emotionally as well.

Other benefits include earlier disposition with shorter hospital length of stays as well as decreased re-admissions. Once an ED patient becomes an inpatient, there is often a delay in consulting palliative care even when the patient is clearly at end of life thus denying the opportunity for meaningful contribution from the palliative care service.

Bringing Palliative Care into the ED

At this point in my career in emergency medicine, I realize that we have to do better!  Sometimes that best approach is, “Don’t just do something, stand there!”  This is a very hard pill for an emergency physician to swallow as it flies in the face of what we have been trained to do.

This is why palliative care needs to be integrated into the ED.  This is why I continue to be an emergency physician, but have become a part-time palliative care physician as well.  My favorite consults are the ones that come from the ED!

Last Updated: November 5, 2018