Patients who live with complex serious illness are a large proportion of the patients we see in the emergency department. The ED is the staging area for patients at all critical points of their serious illness. These difficult patients and their families are often bewildered and defensive, having been to numerous specialists and facilities in an attempt to control their illness. We have a unique opportunity in the ED to make a difference. Palliative care principles can be applied in the ED under many circumstances. Discussing serious illness, guiding future care such as code status and advance care planning, prognosticating, managing symptoms, and dispositioning can all be addressed.

The following actual cases illustrate palliative care principles applied to common ED scenarios: the extreme, the game changer, and the mundane. We hope to convey the significant difference that palliative interventions in the ED can make to families, caregivers, and the overall trajectory of the patient’s care.

Case 1: The Extreme

A 69-year-old man presented with hematemesis, headache, and visual changes. He had a history of metastatic prostate cancer and was currently undergoing chemotherapy. On exam, he was very pale with dried blood around his mouth, lethargic, and in moderate distress. While in the ED, he deteriorated rapidly, became unresponsive, and started posturing. During intubation, the medical team also noticed one of his pupils was blown. His blood work showed pancytopenia, including platelets of 5,000.

1. Standard approach: Intubate, resuscitate, computed tomography (CT) scan when stable, and admit to the intensive care unit (ICU).
2. Palliative approach: Invite family to witness the resuscitation, initiate prognosis conversations with wife (early), ask about advance directives, discuss the prognosis clearly and realistically explore the possibility of terminal extubation, provide aggressive symptom management, and admit to floor.

More history was obtained from his wife, who was distraught but able to communicate well. The patient was currently receiving chemotherapy for prostate cancer metastatic to bone. He had received a double dose the week before because the couple were supposed to go on a cruise that week. That morning, he started vomiting, and when the wife got home from work, she saw that it was bloody and he was much sicker than he ever had been. He had no advance directives, but she knew that he did not want to be kept alive by machines. His wife was aware that the chemotherapy was palliative, meaning not curative. He had been tolerating it well so far with minimal side effects and was still very functional at home. They were hopeful for more time.