Susan C. Stone

The Palliative Care Model for Emergency Department Patients with Advanced Illness

BACKGROUND Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patients subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a providers office. Even for patients in whom goals of care are clear, families often need support for their loved ones physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). DISCUSSION Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition. CONCLUSION Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

Treatment Preferences: Impact of Risk and Benefit in Decision Making

Understanding treatment preferences of seriously ill patients is complex. Previous studies have shown a correlation between the burden and outcome of a treatment and the likelihood a patient will accept a given intervention. In this study the Willingness to Accept Life Sustaining Treatment (WALT) survey was used in a predominantly Latino population receiving care at a large urban safety net hospital. Eligible patients were cared for by one of four clinics: (1) human immunodeficiency virus (HIV); (2) geriatrics; (3) oncology; or (4) cardiology. Hypothetical scenarios reflecting outcomes of resuscitation were presented and patients were given information on the burden and outcome of treatment. They were then given the option of accepting or declining treatment; 237 completed the survey. Patients in our study were willing to accept a high level of cognitive (vegetative state) and functional (bed-bound) impairment even when the chance of recovery was exceedingly low.