Journal of Palliative MedicineVol. 24, No. 5 Letters to the EditorFree AccessGoals-of-Care Course for Emergency Physicians during the COVID-19 PandemicMari Siegel and Erica WestlakeMari SiegelAddress correspondence to: Mari Siegel, MD, Department of Emergency Medicine, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140, USA E-mail Address: Mari.siegel@tuhs.temple.eduThomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.*Current Affiliation: Temple University Hospital, Keystone Palliative Care, Philadelphia, Pennsylvania, USA.Search for more papers by this author and Erica WestlakeSidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.Search for more papers by this authorPublished Online:19 Apr 2021https://doi.org/10.1089/jpm.2021.0017AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Dear Editor:The emergency physician (EP) has been viewed as a factotum since the field's inception. Despite being able to pivot between delivering children, dealing with trauma cases, and handling broken bones, emergency department (ED) physicians lack the training to aid their declining patients. The ED visit generates a teachable moment for the patients in terms of how to shape the rest of their care, considering ED visits often signal the beginning of patient deterioration in those with serious illness.1 This gap in training has been highlighted by the coronavirus disease 2019 (COVID-19) pandemic, where many COVID-19 patients arrived to the ED, at risk for rapid deterioration, and often lacking advanced directives. It became imperative for ED physicians to gain another skill, leading goals-of-care (GOC) conversations with patients. In response to this need, an EM/IM/Palliative Care boarded physician implemented a Goals-of-Care Refresher Course for ED faculty at an academic urban ED.GOC discussions enable the medical team to match a patient's goals with recommended interventions and enable patient-centered care at all stages of illness. These discussions become the cornerstone of patient advocacy in situations when patients cannot speak for themselves. Having this framework for how patient goals inform interventions allows for an appropriate use of resources in accordance with patient wishes, and promotes care of the patient, not just treatment of the disease.Frameworks including REMAP, REMAP with informed ascend, and Five Minute ED Goals of Care, were covered in the course to provide a mental map that providers can fall back on if they are having difficulty navigating the discussion.2–4 Specific language was introduced that conveys empathy and alignment with the patient, and offers a reflective and nonjudgmental assessment of the patient's goals and values. Providers were encouraged to ask permission both to give serious news and before giving recommended treatment plans. The phrase “I wish” was encouraged when providers respond to patient emotions, to impart nonabandonment without providing false hope, or diminishing the seriousness of a disease. In the second part of the GOC refresher course, participants were paired together to role play to practice these techniques.The ethical principal of informed assent became a popular debate topic when the medical world feared we would have to ration care because of the COVID-19 pandemic and, as such, was included in this course.2 Informed assent posits that not all interventions are right for all patients. It advances that physicians should use their expertise to elect not to offer intubation or cardiopulmonary resuscitation (CPR) to a patient for whom the procedure is exceedingly unlikely to provide benefit, as demonstrated by data that the death rates for intubated patients >65 years with comorbidities were uncommonly high.5Results from the voluntary survey, taken by 17 of the 40 course participants (43%), demonstrated that over two-thirds of EPs have never had GOC training in any format, and that a short lecture and practice can positively impact comfort levels for providers (Fig. 1). GOC training and discussions are essential to ensure value concordant care.FIG. 1. Survey results demonstrating comfort levels with GOC discussion before and after course. GOC, goals-of-care.Authors' ContributionsM.S. contributed to the study concept and design, acquisition of the data, and drafting and critical review of the article. E.W. contributed to the analysis and interpretation of the data, and drafting and critical review of the article.
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Jun 9, 2021
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