To achieve this, we need to better understand which patients should receive these services. Consider the following case:

A 54-year-old male presents to the emergency department with stage-4 lung cancer, a history of metastatic disease to the brain, and a complete white out of the right lung secondary to tumor and effusion. He was identified as needing a palliative consultation by the emergency-department palliative care triage-screening tool. The palliative team, consisting of the emergency physician and palliative registered nurse, saw the patient and family in the exam room. The conversation was started by asking the patient what he thought was going on. His sister answered that he was dying. “There is nothing more to be done, but he is so short of breath and uncomfortable,” she said. The patient continued to nod his head in agreement. The palliative team asked if they could partner with the patient and his sister to develop a plan. Together, the palliative team, the patient, and his family developed a plan. This patient was sent in by his doctor for hospital admission; however, during the discussion, it was discovered that one of the patient’s goals was to spend as little time as possible in the hospital. The team agreed that this partnership would manage the patient’s symptoms and notify the hospice case manager to see if he was the right fit to help the patient manage his illness at home with his family. Within four hours, his dyspnea was relieved and he was admitted to inpatient hospice for stabilization. That would give everyone time to prepare so that he could go home for his final days. Two days later, he was home with his family and pet cat.

This is not an unusual case to present to the emergency department. As a matter of fact, this is the type of patient most emergency departments in the country see every day. This emergency department may be unique in that they have hospice/palliative medicine–certified emergency physicians on call 24-7 for palliative consults.

In this case, there are several key elements to a palliative referral, which can be achieved using in-house or community resources. The key elements when considering referral of seriously ill patients are to identify patients who can benefit from palliative intervention, know how to have the conversation, be the best symptom manager, and understand the role of hospice and palliative services.

Palliative medicine is the newest frontier in EM. ED visits are the logical place and time; a new skill for EPs in 2014 and beyond.

Key Element #1: Identification of Patients

Screening tools have successfully been used in triage for many aspects of emergency-department care. A tool that can easily be adapted for triage screening is a simple yes-or-no question: “Would you be surprised if this patient died within the next six months?” Any patients who have a serious illness with a possible death within six months are candidates for a palliative discussion. This is the critical first step, whether initiated by the emergency physician or the consult.

Key Element #2: Having the Conversation

The initial case presentation of the 78-year-old woman with pancreatic cancer illustrates a potential candidate for palliative care and possibly hospice. How do you start the discussion? A shift in demeanor for the emergency physician is required. Take the time to connect with patients and their families. Sit and have a one-on-one intimate conversation; this can be facilitated by the emergency physician or the consult.