Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care interventions for ED patients. Many patients in the ED may benefit from palliative care screening and referral. Multiple ED-based palliative care screening and referral projects have been undertaken, but there has been no study of these projects or their effect. The objective was to conduct a systematic review and critical analysis to evaluate the approaches, methods, and tools used to screen and refer patients to palliative care services in the ED. The PubMed database was searched for relevant titles. Three reviewers independently selected eligible studies that addressed palliative care screening and referral in the ED. Eligible studies described and evaluated a palliative care screening tool, assessment, referral modality, or consultation aimed at identifying patients appropriate for palliative care. Studies that evaluated the incorporation of a palliative care approach to the care of an emergency patient or in an emergency situation, including hospice care or end-of-life-care, were also reviewed. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. Four studies met inclusion criteria. All four were reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for palliative care needs; however, evidence base for the screening approach was lacking in three of the four studies. Each study required additional ED personnel to perform screening and referral and success was limited by availability and consistency of these specialized personnel. All four of the studies were successful in increasing overall rates of palliative care referral or screening. Other outcomes varied by study. Palliative care screening and referral is possible in the ED setting. Further evidence for the development of an effective palliative care screening and referral process is needed. We recommend a screening guide based on a synthesis of available evidence.