A 47-year-old woman with metastatic breast cancer who is being followed by home hospice is brought to your emergency department by ambulance for uncontrolled pain after a frightened family member calls 911.

A 65-year-old man with advanced COPD arrives in your ED with severe shortness of breath. His wife is adamant he does not want to be intubated again and shows you a copy of his “Five Wishes.”

A 92-year-old woman with dementia is transferred to your ED from her nursing home for weakness. She is minimally verbal at baseline per the paramedics and now appears to be in septic shock. She arrives with an advance directive indicating “Do Not Resuscitate” and a nursing home transfer sheet that states “no heroic measures.” Her son arrives and says he wants “everything done.”

Cases like these should be familiar to anyone practicing emergency medicine. These patients and their families could all benefit from the involvement of a palliative care service, and as these programs grow, emergency providers should expect to see more patients followed by a palliative care service.

But what exactly is palliative care? What distinguishes it from hospice care? And what is (or is not) implied when a patient is being treated by a palliative care service or hospice? Smith et al. (Ann. Emerg. Med. 2009;54:86-93) found that there was significant confusion and discomfort among emergency physicians in caring for patients with palliative care needs. They note both attitudinal and structural obstacles in the emergency department to responding well to these needs, as well as recurring (and mistaken) themes such as the belief that palliative care is equivalent to hospice or end-of-life care.

Palliative care is an organized approach for caring for patients living with life-threatening or severe advanced illness. Hospice and Palliative Medicine is also a board-certified medical specialty, approved by the American Board of Medical Specialties in 2006. The American Board of Emergency Medicine is a cosponsoring board. The specialty encompasses both hospice care (where patients no longer pursue life-prolonging therapies, and their expected survival is 6 months or less) and the broader, and generally longer, care of patients with chronic, progressive illnesses who have significant symptom burdens but who want to continue life-prolonging therapies.

Pain control is the most obvious area of symptom management and one where the typical E.D. practice can present challenges.