Palliative Care Guidelines Call for Equipping Frontline Providers to Meet Growing Need
As the U.S. population ages, there is a growing need for clinicians skilled in primary palliative care. Such skills include the ability to assess for need, engage in advance care planning discussions, and provide appropriate care for symptom management that aligns with patients’ wishes. Considering the volume of patients who access care through EDs annually, experts note emergency clinicians often are in a position to provide primary palliative care to those with serious or life-threatening conditions.
While some clinicians are more comfortable in this role than others, until recently there has been a dearth of information on best practices for providing primary palliative care in this setting. To help bridge this gap, an ED palliative care expert panel has developed recommendations that cover how to screen and assess for palliative care needs, manage such care needs, conduct goals-of-care discussions, develop good processes for palliative care or hospice consults, and facilitate transitions of care, all with the unique characteristics and needs of the ED in mind.1
Anthony J. Loffredo, MD, lead author of the guidelines, says he recognized early in his career many ED patients presented with unmet palliative care needs in part because clinicians were so overwhelmed with other duties. “I also recognized in myself that if I wanted to help address these needs, I needed a guide and more training,” says Loffredo, director of emergency department palliative care at Cedars-Sinai Medical Center in Los Angeles. “Standards of care were being put forth by experts in the field, but the idea of merging palliative care and emergency medicine was still in its infancy.”
Over the past two decades, the number of emergency clinicians who are double-boarded in palliative care and emergency medicine has grown, but not enough to meet the needs of the aging population.
“Meeting the palliative care needs of our patients now and in the foreseeable future will require the provision of primary palliative care by frontline ED clinicians,” Loffredo offers.
Interestingly, as a frontline emergency clinician, Loffredo is quick to agree EDs are overwhelmed, and that administrators and policymakers must be careful about asking emergency clinicians to handle more. “At the same time, sometimes doing better can mean doing less, such as less inappropriate critical care when that care is not concordant with the patient’s goals,” Loffredo suggests. “I will also admit that changing ingrained habits is often not easy. A humble and dispassionate long-range view can really help.”
Loffredo adds EDs do not have to implement every recommendation or improvement all at once; they can start small. “Maybe think about how [you] might have the most impact with the least amount of effort,” he says.
Sangeeta Lamba, MD, MS-HPEd, co-author of the guidelines, echoes many of these sentiments, but also says palliative care is not really separate from emergency care.
“Many so-called palliative care-related practices, such as controlling symptoms effectively, communicating effectively, and aligning care to the patient’s values, are also core to good quality ED care,” explains Lamba, vice chancellor for diversity and inclusion at Rutgers Biomedical and Health Sciences. “Primary palliative care skills are really our skill set in the ED; we do this all the time, 24/7. Therefore, integrating these best practices and defining aspects of primary ED palliative care for all ED clinicians is just good, overall patient care.”
Lamba admits there are unique challenges for EDs. Most notably, there are the time constraints and the demands for making major intervention decisions regarding life support — sometimes made with limited information and in rapidly evolving, often-unclear and unstable clinical scenarios. “Often, the patients we see are there in the ED from sudden, unexpected, often-disabling, or catastrophic events that has family totally unprepared and in shock,” Lamba observes. “The practice of palliative care in the ED is also uniquely nuanced in order to meet the needs of our patients.”
For example, while there are several screening tools that can be used to assess palliative care needs, Loffredo, Lamba, and colleagues used what they refer to as the surprise question for assessment purposes. Clinicians ask themselves whether they would be surprised if the patient they are treating died within the next year.
“[We] like the surprise question because it is effective, easy to use, and easy to implement,” Loffredo says. “You can adjust the time frame based upon the palliative care needs that you or your organization may want to address.”
At Cedars-Sinai, Loffredo notes he and colleagues decided to focus on the needs of critically ill patients. Clinicians might ask themselves whether they would be surprised if the patient they are treating died during this hospitalization.
“If we would not be surprised, then we could focus on code status, determining the burden tolerance of critical care interventions, and the patient’s minimal acceptable quality of life,” Loffredo notes. “This can be difficult in the ED if the issues have never been addressed.”
For cases with an expanded timeline, perhaps a year or longer, a tiered approach might be appropriate. Here, the clinician could ask the patient about a healthcare proxy or surrogate decision-maker, make a referral to palliative care, or suggest further discussions with family or providers.
According to the guideline authors, part of the assessment process involves engaging in a goals-of-care discussion with patients who present with palliative care needs. Some emergency practitioners might be uncomfortable with these discussions, but Loffredo notes many of his colleagues are excellent at conducting these conversations. Those who lack the skills needed to manage this task effectively can improve with appropriate training. “Luckily, communication skills can be learned just like the skills that we’ve all learned to do emergency procedures,” Loffredo says. “The conversations also sometimes can be quite straightforward.”
For instance, Loffredo notes he often asks patients in the ED if they have ever talked to anyone about their preferences for care if they become seriously ill. It is an easy way to start a goals-of-care conversation. Other providers can pick up where a conversation in the ED leaves off.
“Patients and families just need more time to think about the issues,” Loffredo says. “It is totally appropriate in the ED to just introduce certain topics, such as a healthcare proxy.”
If there are no proxies, clinicians might suggest patients think about who knows them well and would express appropriate care preferences in the event a serious illness strips them of decisional capacity.
Palliative care providers are trying to make serious illness communication skills a part of resident training. “I am also participating in a serious illness communication skills initiative at my own institution,” Loffredo says. “That initiative currently is centered on physicians, but will hopefully be expanded to other healthcare professionals soon.”
Lamba says EDs can diminish the barriers to providing effective primary palliative care. “Using and embedding structures within other routine practices of the ED are more likely to be effective than adding on tasks that will require added time or staff,” she says. “For example, [embedding] screening for palliative care-eligible patients within triage processes and [implementing] automatic electronic triggers that pull up advance directives and help flag for [palliative care] consult reminders may work best since they are tools to assist the provider.”
Loffredo advises clinicians to consult with each other to identify opportunities for improvement. “Find those with energy for this topic and brainstorm,” he says. “Where is there potential for significant impact with a relatively simple solution?”
Identify a metric or set a goal, define the interventions, and set a schedule for reporting performance. “Frontline providers [can provide] key information to guide this whole process, and it gets the clinicians engaged,” Loffredo says. “Engaging the right stakeholders, such as upper-level leadership, is also critical and can help provide resources, such as administrative support.”
The new guidelines should offer emergency leaders some ideas on how to move forward while also helping them “establish a reasonable standard of primary palliative care,” according to the authors.
However, the authors also expressed hope this effort is just a starting point, that national benchmarks, policies, and research specifically aimed at the provision of palliative care in the emergency setting will follow.
REFERENCE
- Loffredo AJ, Chan GF, Wang DH, et al. United States best practice guidelines for primary palliative care in the emergency department. Ann Emerg Med 2021;78:658-669.
As the U.S. population ages, there is a growing need for clinicians skilled in primary palliative care. Such skills include the ability to assess for need, engage in advance care planning discussions, and provide appropriate care for symptom management that aligns with patients’ wishes. Considering the volume of patients who access care through EDs annually, experts note emergency clinicians often are in position to provide primary palliative care to those with serious or life-threatening conditions.
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