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.

In other words, while hospice care falls within palliative care, not all palliative care patients are at the end of life. One of the key concepts in palliative care for patients with chronic progressive illnesses is replacing the traditional all-or-nothing approach – exhausting all diagnostic and therapeutic measures and then sending a patient to hospice in the final days of life – with an approach that gradually transitions over time from an emphasis on life-prolonging measures to a focus on comfort.

The American Academy of Hospice and Palliative Medicine (AAHPM) states that the purpose of palliative care is to “prevent and relieve suffering and to support the best possible quality of life for patients and their families regardless of the stage of the disease or need for other therapies; [palliative care] can be delivered at the same time as life-prolonging care or as the main focus of care. [It is] achieved through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and cultures.”

All emergency department patients, especially those approaching the end of life, should expect skillful management of distressing symptoms. Symptom management is a cornerstone of palliative care and in many settings is the primary role of a palliative care service. Pain control is the most obvious area of symptom management and one where the typical emergency department practice can present challenges.

Emergency physicians order and prescribe opioid and non-opioid analgesics routinely. At the same time, these physicians are often confronted by patients who misuse or divert pain medications and “shop” from emergency department to emergency department, making physicians reluctant to prescribe large amounts. Further, emergency medicine training cautions physicians to avoid respiratory, cardiovascular, and mental status complications that can result from excessive dosing of acutely ill and often unstable patients.

And yet patients with advanced illness, particularly patients with advanced cancers, can have extraordinary analgesic needs, requiring doses that would unnerve many physicians (not to mention nurses confronted with these orders). A “routine” dose of 4 mg of IV morphine in a patient normally on the equivalent of 400 mg of oral morphine a day is unlikely to do much for such a patient in a pain crisis.

for some emergency physicians, palliative care represents an opportunity to develop an additional skill set.

Opioid dosing and conversions, use of adjunct and non-opioid medications, and management of side effects are all key skills for specialists in palliative care. In addition to pain, symptoms commonly managed by palliative care providers include dyspnea, nausea and vomiting, constipation, diarrhea, delirium, and anxiety and depression.

In addition to utilizing medications to relieve symptoms, palliative care services generally employ specially trained nurses, social workers, and chaplains to provide spiritual and psychosocial support for patients and families.

Given the increase in patients living longer with chronic progressive illness and the complexities of advance care planning and symptom management, palliative care can provide many benefits to patients and providers in the emergency department. For some emergency physicians, palliative care represents an opportunity to develop an additional skill set, scope of practice, and even subspecialty board certification. For many, it represents an opportunity to bring added insight and knowledge to the care of patients dealing with chronic symptoms and functional decline, and to those approaching the end of life. Perhaps for most, it is beneficial simply to know that palliative care exists, that patients and families can be offered palliative care services, and that consultants can assist in symptom management and in clarifying goals of care.

It is hoped that this will lead more emergency physicians to include “needs a palliative care consultation” in the patient’s list of diagnoses. If so, patients and their families, as well as emergency physicians in the midst of busy shifts, will benefit.

Dr. Bryant is a member of ACEP’s Ethics Committee and practices inpatient palliative care at Exempla Saint Joseph Hospital and Exempla Good Samaritan Medical Center in Denver.