If not us, then who? Palliative care referral from the emergency department.

Abstract

It is a common enough event in the emergency department (ED). A patient with metastatic cancer presents for emergency care, perhaps due to the malignancy, perhaps due to a side effect of his or her ongoing therapy, but most frequently for pain.1 We in emergency medicine (EM) have traditionally excelled at the diagnosis and stabilization of oncologic emergencies and perform adequately in treating overt pain and other symptoms while the patient is there in front of us. However, what about when the patient goes to the inpatient floor? Certainly, we think, the inpatient service will take care of it. It's not our place to step in. If we can recognize that the patient is in pain or distress, our colleagues, who are excellent and well-meaning clinicians in their own right, will certainly identify the need for symptom control, right? Unfortunately, it seems that may not be the case. Kistler et al.2 studied the effect of initiating palliative care referrals from the ED. In this trial, 134 cancer patients with advanced disease requiring admission from the ED were randomized to either an intervention or usual care after meeting the criteria for the study. The intervention patients each received a palliative care consultation placed directly from the ED, while the usual care patients had no ED consultation prior to admission, thus allowing the inpatient team to consult palliative care if desired. Unfortunately, only 12 of 66 (18%) patients in the usual care arm received palliative care consultations. Compare this to the ED intervention group, in which 60 of 68 (88%) had documented palliative care consultations during their hospitalizations. The study has merit as a pilot proof of concept, but requires confirmatory work and expansion of scope to establish external validity and generalizability. The patient population is based on a single center, with a motivated set of ED champions spearheading the effort. The process by which patients in the usual care arm were referred to palliative care was not standardized; however, this likely mirrors real-world practice. Finally, nonclinical research staff actually placed the consultations. In an overcrowded, overly busy ED, this could be perceived as “just one more task” asked of the ED physician. We found it interesting, yet mildly concerning, that researchers needed permission from the patient's medical oncologist prior to approaching the patient for enrollment. While we realize that this was, in all likelihood, a necessary step to obtain buy-in from all stakeholders for the research protocol, it still evokes unpleasant echoes of a time when the emergency physician was seen as little more than a stand-in for the specialist. In this clinical arena, as in all others in EM, it behooves us to independently understand and act on the relevant best practices to provide the best care for our patients. However, the researchers showed initiative in an area that our national leadership in EM, as well as other specialty societies, has charged us to engage. The 2013 Model of the Clinical Practice of Emergency Medicine, endorsed by all major national EM organizations, explicitly includes palliative care within the scope of our practice.3 The American Board of Emergency Medicine has sponsored subspecialty certification for emergency physicians in hospice and palliative medicine. The American Society of Clinical Oncology has encouraged early involvement of palliative care in patients with metastatic disease, as opposed to waiting until end-of-life discussions occur.4 This recommendation is based on evidence that patient quality of life and symptom control are improved without evidence of increased cost or shortened life with early palliative care involvement. The literature base on ED referral to palliative care continues to evolve. While we have seen that ED referral to palliative care can decrease inpatient length of stay,5 there is yet an insufficient evidence base to evaluate the direct effect of ED referral on other metrics of clinical care and quality of life.6 It would seem intuitive, though, that if palliative care involvement, regardless of origin, is beneficial, and that inpatient referral patterns are suboptimal, then the ED may have an opportunity to enhance the lives of our patients beyond the walls of our immediate environment. This is our place to act. These are our patients. Making important treatment options more accessible from the front door of the hospital is what we do. Downstream effects of ED-initiated interventions cannot be ignored. The work by Kistler et al. in this issue of Academic Emergency Medicine suggests that we can have an effect on a process that alleviates suffering and improves quality of life. We have the ability to do better by our patients. As a profession we should consistently be aware of new opportunities to advocate for our patients' right to a quality of life. In memory of Joseph Banyasz, PhD.