The Choosing Wisely campaign is making a big push to involve palliative care in the emergency department. Also, Michael J. Gerardi, MD, FAAP, FACEP, President of ACEP, has put palliative care in his strategic plan for this year, but why the ED?

We are caring for many patients with advanced chronic obstructive pulmonary disease, congestive heart failure, dementia, and other chronic conditions. More than 133 million Americans, or approximately 45 percent of the U.S. population, have at least one chronic disease.^1,2 These chronic diseases are responsible for more than 1.7 million, or seven out of every 10, deaths in the United States.^1–3 For the seriously ill, the ED is a staging area, which makes ED providers positioned to “screen and intervene.”⁴

Ideally, most conversations about a patient’s goals or prognosis wouldn’t happen in the ED, but they do. Often, the ED sees chronically ill patients declining without them understanding their waning medical situation or “having the talk” with their provider.⁵ This is likely due to a combination of factors: shrinking availability of primary care, lack of education and training by providers to discuss prognosis, and our silo system of medical subspecialties.^5–10 In 2013, the US Department of Health and Human Services predicted the need to increase the number of primary care providers (PCPs) by 14 percent. However, the expected number of PCPs will only increase by 8 percent.¹¹

The average Medicare patient has seven different doctors, with the more chronically ill patients visiting approximately 11 doctors in seven different practices within the same time frame.¹¹ Patients still aren’t getting the opportunity to talk about the “big picture” (their goals) or their health’s decline.¹⁰

Often, these patients enter a cycle of nursing home to hospital to subacute rehab and back again, where they eventually spend more time in the hospital and less time at home without a clear benefit from each recurrent hospitalization.⁸

Over the past five years, emergency medicine has increasingly become an important place to implement palliative care. Often, emergency providers are reluctant to take on this responsibility because we are not the patient’s regular doctor, don’t have time, or don’t have the rapport to discuss goals of care or prognosis with a patient.^12,13 Therefore, we defer “the talk” or do not make palliative or hospice care referrals. We must remember that the ED remains a safety net for patients underserved or overlooked by our medical system.^7,14,15 This includes patients who are being underserved by their own physicians who are not informing them of their prognosis and helping plan for their medical future.^8,16 If not us, then who?

References

1. Centers for Disease Control and Prevention. Chronic disease overview. 2015. Accessed April 6, 2007.
2. Centers for Disease Control and Prevention. FastStats. 2015. Accessed April 3, 2015.
3. Robert Wood Johnson Foundation. Chronic conditions: making the case for ongoing care. 2015. Accessed April 3, 2015.
4. Rosenberg M, Lamba S, Misra S. Palliative medicine and geriatric emergency care. Clin Geriatr Med. 2013;29(1):1-29.
5. Meo N, Hwang U, Morrison R. Resident perceptions of palliative care training in the emergency department. J Palliat Med. 2011;14(5):548-555.
6. Penrod J, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
7. Center to Advance Palliative Care. Making the case for ED-palliative care integration: a presentation of the IPAL-EM Project. 2015. Accessed April 3, 2015.
8. National Quality Forum. Aligning our efforts to transform America’s healthcare: national priorities and goals. 2008. Accessed April 3, 2015.
9. Grudzen C, Richardson L, Hopper S, et al. Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. J Pain Symptom Manage. 2012;43(1):1-9.
10. Lamba S, Pound A, Rella J, et al. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med. 2012;15(5):516-520.
11. Health Resources and Services Administration Bureau of Health Professions: National Center for Health Workforce Analysis. Projecting the supply and demand for primary care practitioners through 2020. 2015. Accessed April 3, 2015.
12. Lamba S, Nagurka R, Zielinski A, et al. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med. 2013;16(2):143-147.
13. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6):563-568.
14. Weber E, Showstack J, Hunt K, et al. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study. Ann Emerg Med. 2005;45(1):4-12.
15. Moss A, Lunney J, Culp S, et al. Prognostic significance of the surprise question in cancer patients. J Pain Symptom Manage. 2010;39(2):346.
16. American Academy of Hospice and Palliative Medicine. Accessed April 3, 2015.
17. Center to Advance Palliative Care. About palliative care. Accessed April 3, 2015.
18. Ciemins E, Blum L, Nunley M, et al. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med. 2007;10(6):1347-1355.
19. Penrod J, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855-860.

The authors are members of the ACEP Palliative Section. Dr. Goett is assistant professor and assistant director for advanced illness and bioethics in the departments of emergency medicine and palliative care at Rutgers New Jersey Medical School in Newark. Dr. Fetzer is an emergency medicine attending physician at Advocate Health Care and director of palliative care at Rainbow Hospice and Palliative Care in Mount Prospect and Park Ridge, Illinois. Dr. Aberger is core faculty in emergency medicine and palliative medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey. Dr. Rosenberg is chairman of emergency medicine at St. Joseph’s Healthcare System and associate professor of clinical emergency medicine at New York Medical College.