Palliative Care in the ER: Patients May Be Ready To Let Go, But Doctors Are Busy
The doors of an ambulance burst open. Doctors and nurses rush to receive a moaning patient. The first-responders communicate as quickly as they can as the patient is rushed to the emergency room.
“Can you hear me? Can you tell me what’s wrong?”
Symptoms are determined.
Treatment is administered.
A life is saved.
But in the flurry of words and actions, there have been no real conversations, and as the population ages, life at all costs may not be what patients are seeking.
Such is the case many times in the emergency room, but not because doctors and nurses don’t care about their patients. It’s that emergency rooms are wired react to emergencies. They fix problems and save lives. There is not time to think of palliative care.
Palliative care focuses on patient well-being and comfort. It seeks to primarily address quality of life issues rather than underlying diseases. It is also known as end-of-life care, but it’s also appropriate for patients with serious illness who are still seeking treatment. Palliative care seeks to make a patient comfortable during their illness, whether that illness is terminal or not.
For some patients, being presented the option of palliative care can help them understand, perhaps for the first time, that there is an option besides using every last breath to fight an illness. It provides a path to end life on their terms.
For many seriously ill patients, this is just what they are looking for. A review of Medicare recipients in the United States found that the majority over 65 preferred palliative care options over life-extending treatments. But if that’s the case, why go to the ER in the first place?
For some, there are transportation issues. Someone experiencing serious symptoms may not be able to drive themselves or wait for a bus ride, and calling emergency services is their only option. Or a patient’s family may find their symptoms distressing and think an emergency room visit is necessary.
Others may not have been presented with the information required to make a decision, such the New York man who went to the ER five times in six months until he finally found out he had cancer. He then chose hospice care so he could spend his final months at home.
Emergency room doctors are aware that an important need is being left unaddressed. In a 2016 survey, only about 10 percent of emergency room medical staff felt that they were utilizing an effective strategy to screen for palliative care needs.
Dr. Kei Ouchi told NPR News that he remembers a man sobbing when he found out his terminally-ill wife had been given a breathing tube; the man knew his wife wouldn’t have wanted that kind of intervention. But once the tube was in, he could not bear to have Dr. Ouchi take it out.
Doctors are looking for a system that helps them easily identify which patients might benefit from having the option of palliative care. A tool developed at Brown University, P-CaRES, aims to do just that. The P-CaRES tool populates questions on a patient’s electronic medical record before they are admitted to the hospital: Do they have cancer? End stage renal disease? Uncontrolled symptoms? Would the doctor be surprised if they passed away in a year or less?
The goal is to help doctors to switch from emergency-room mode and consider if a broader conversation might be appropriate. Eighty-seven percent of emergency medical staff who tried the tool thought it would likely benefit patients. Nearly that amount thought it would help seriously ill patients access palliative resources.
Some emergency room staff question the feasibility of conversations about palliative care in emergency rooms, and there aren’t currently enough medical staff trained for hospice or palliative care to fill the need of the aging population.
Dr. Corita Grudzen, an emergency doctor in New York, doesn’t think that there’s time to wait. The need is growing now. “We’ve got to teach cardiologists, intensivists, emergency physicians, how to do palliative care,” Grudzen said. “We really have to teach ourselves the skills.”
Emergency doctors are trained to save lives. When an ambulance screams in, they are ready to do what it takes to keep hearts beating. It will take some time to implement a mindset that pauses, once the flurry has died down, to ask if that’s what the patient truly wants.