Thursday, July 23, 2009

Improving Palliative Care in the ED

Annals of Emergency Medicine has a couple of related articles about palliative care in the ED.

First is a general discussion about PC in the ED, it's kind of a 'palliative care 101' for ED clinicians and talks about how pc skills are important in the ED setting. It also discusses HPM board certification for emergency medicine physicians.

The other article is a qualitative research study about the experiences and attitudes of emergency department clinicians about providing palliative care and EOL care in the ED. The study involved focus groups of clinicians (docs, nurses, social workers, and techs; n=26; 54% docs including residents) from 2 academic EDs in Boston, and used open ended questions about experiences with, understanding of, and attitudes towards EOL and palliative care in the ED setting.

The results are revealing, and describe deep concerns and frustrations and feelings of clinical inadequacy in these situations: lack of training in symptom management, prognostication, and communication; uncertainty about how to address conflict/unclear goals in an emergency setting; major frustration with outpatient providers about not addressing EOL care/goals/issues/treatment limitations prior to a patient's presentation as well as with systems issues to do with documentation of treatment preferences/DNR orders etc. (sort of stuff that the POLST paradigm in particular is designed to address; still requires however someone to do that prior to a patient showing up in extremis in an ED).

That last issue in particular is one that I've heard from a lot of EM physicians. Clearly the ED is the worst imaginable place to have these conversations/make these decisions. By necessity, however, it is sometimes the right place to have those discussions, but the general sense is that the providers feel not only resentment about having to do it but inadequacy. One doc noted that they find themselves second guessing what they're doing because it is so inconceivable to them that no one else had had these conversations before: “Having these conversations in the ED causes a lot of consternation. I wonder, ‘Am I doing the right thing by this person? Why hasn't somebody else talked to this person about it? Why does it come to me to end up talking to this person?'” The context presented by the first paper (discussing palliative competencies necessary for ED providers, etc.) is obviously some part of the solution but it won't change the larger/deeper issues of these conversations generally happening too late.

One last intriguing discussion in the paper is about the ED providers' reaction to hearing a definition of 'palliative care.' The definition they were provided seems to be standard WHO-ish language: 'The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care can be delivered at the same time as life-prolonging care or as the main focus of care. Palliative care is achieved through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and culture(s).' They mention some were surprised about palliative care not necessarily implying EOL care, but also this:

Several providers (2 attending physicians, 3 residents, 2 nurses, and 1 social worker) expressed frustration that the structured definition of palliative care seemed too broad to be clinically useful. One provider noted, “This seems more of a definition of what good emergency care should be at any given stage than specific for palliative care.”
Or, in fact, what good medical care in general should entail. I couldn't agree more, and this brings up again discussions we've had on the blog before about major problems we have as a professional community about defining what we do, particularly as we define it away from (or at least more broadly than) EOL care. People 'get' the EOL care aspect. When I told my mother what palliative care was years ago her initial reaction was something like Isn't that what all doctors should do? Obviously, hell yes, absolutely, but then I started trying to describe what palliative specialists do and had a hard time. It's tough defining succinctly, without taking up a whole paragraph, what it is that specialist PC clinicians/teams do (outside of hospice-specific settings). I think this is a real problem because clinicians/clinical services which aren't used to specialist PC, don't 'get it' or whatever (see for instance last week's post about CHf), how are they supposed to understand what we do such that they know when/how/why to involve us. Especially because they read that definition and say to themselves Well I do that (or at least I know I should be doing that). And of course you could argue that 'they' often don't do that very well, or don't realize that it could be done much better, but that's not very, umm, collegial. Of course most clinicians don't have a problem consulting other specialists when they feel like they need help, which makes me wonder if the major problem is a lack of appreciation of what meticulous, patient-centered symptom management and communication actually looks like.

Anyway: my challenge for anyone reading this is to share your 1 sentence description of what specialist palliative care means and/or why it is needed? Or at least short description, if not 1 sentence.

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