Emergency Medicine Physicians' Perspectives of Providing Palliative Care in an Emergency Department

Abstract

This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

Introduction

Palliative care has clearly demonstrated the ability to improve the quality of care for patients with advanced illness. Bringing this care to patients in the emergency department (ED) has become an area of increased interest. Yet there are no definitive studies or models for delivery of care in the ED. In our health care system, patients gain access to the hospital through the ED, where important decisions are made such as defining goals of care and early management of distress. As in other settings, the ED should benefit from palliative care and increasing quality of care.¹ There is initial evidence suggesting that incorporating palliative care services in an urban ED increased patient and family satisfaction with symptom relief and promoted the utilization of hospital-based palliative care services and hospice in elderly patients.^2–4 Hospice enrollees have benefited from hospice admission with a decrease in the use of the ED.⁵

Safety net hospitals care for a vulnerable population. Most of these patients have poor access to care and utilize the ED for many of their needs,^6,7 including palliative care.^8,9 There may be additional benefits to early involvement by the palliative care team from both a quality and financial perspective in this setting.^10,11 As the merging of palliative care into the ED continues to be explored, studies investigating provider and patient perceptions are useful in understanding potential barriers and opportunities of bringing palliative care (both primary by ED providers and secondary by the palliative care service) into daily ED practice. This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles.

Methods

Setting

The setting for this study is a large, public, urban academic medical center with an ED that serves more than 100,000 patients each year and serves as a major trauma and burn center. It serves a multicultural population that is living well below the poverty line. There is an inpatient palliative team that responds to ED consults during the week. All emergency physicians had the opportunity to attend 1 to 2 hours of dedicated lectures on palliative care topics.

Participants and sampling

Physicians were randomly selected from a list of all emergency medicine housestaff (PGY-2-4) (n=26) and attending physicians (n=38) and offered a small incentive to participate. All attending physicians were board-eligible or board-certified in emergency medicine and worked full-time in the ED. Interviews were conducted by trained study personnel and followed a semi-structured interview guide (see Appendix).

Measures and analysis

Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Interviews were recorded and professionally transcribed. This study was approved by the University of Southern California Institutional Review Board.

The qualitative analysis utilized a “constant comparative” approach,¹² an aspect of grounded theory that entails the simultaneous process of data collection, analysis, and description. In this process, data are analyzed for patterns and themes to discover the most salient categories, as well as any theoretical implications that may emerge. As data are collected, they are immediately analyzed for patterns and themes, with the primary objective of discovering theory implicit in the data. ATLAS.ti software (ATLAS.ti GmbH, Berlin, Germany) was used for coding and analysis of relationships between and within text segments. Codes related to provider expectations, benefits, family, challenges, and recommendations were included in the analysis. Axial coding was then conducted to piece the data back together to fully describe the issues. This process of axial coding led to the structure of the present study, which describes 1) challenges in providing palliative care in the ED; 2) benefits to the patient, family, and provider of providing palliative care; and 3) recommendations for education and training.

Results

Participants included 24 emergency medicine physicians (12 residents and 12 attending physicians). They were predominantly male (62%). The attending physicians varied in experience from 1 year to more than 20 years of experience.

Perceptions and definitions of palliative care

Respondents were asked to define palliative care based on their experience and training. In general, most equated palliative care with comfort care. Specifically, most physicians felt that palliative care was something provided at the end of life, something that would improve “quality of life” for individuals with terminal illness over “quantity of life.”One physician expressed that he felt that palliative care, particularly in the ED setting, was “managing what people's wishes are and helping patients/families decide what they want in terms of end-of-life care.”

Challenges

Several themes were identified that were barriers to incorporating palliative care into the ED. (See Table 1.) These included environmental, training, and cultural aspects of emergency care.

Table 1.

Challenges

Environmental

Unclear whether ED can support this type of care

Interruption to work flow

Lack of patient follow-up

Lack of trust; no long-term relationship

Training

Palliative care at odds with medical training (trained to cure and “fix” things)

Lack of communication skills training in emergency medicine

Cultural

Language barriers

Differing religious and spiritual beliefs about illness, death, and dying

Patient education

Family needs at odds with patient needs

Patient informed decision making

ED, emergency department.

Environmental

Patient flow and the need for quick decision making and lack of bed space were seen as barriers to the provision of palliative care. Respondents felt that palliative care was an important aspect of patient care, but they were not sure if the ED could support that type of care. Respondents noted that discussing the goals of care and prognosis could be time-consuming and the ED was not the ideal place to have these discussions. Providers felt that they could not dedicate the time needed on a busy shift. Interruption to the work flow in an overcrowded ED was a concern. Once stabilized, patients wait to be admitted and a palliative care consult may not be practical.

Physicians felt that the inability to monitor outcomes was a limitation. This was particularly true with prescribing opioid analgesics, and they felt more comfortable if the palliative care team provided guidance. Physicians felt it was important for patients with palliative care needs to receive good follow-up after hospital discharge, ideally by palliative care specialists.

“…getting the palliative care team to give information about prognosis and managing pain as well as assisting with home care is valuable rather than repeat ED visits.”

Emergency physicians' felt it was difficult to develop trust with patients because of the short time spent with patients and lack of long-term relationships. For this reason, respondents felt some discussions would best be initiated in the outpatient setting where the physician has more frequent contact with the patient.

Training

Many ED physicians acknowledged limitations in providing basic palliative care due to lack of training in that area. Several described palliative care as being somewhat at odds with standard medical training where individuals are trained to cure patients and want to “fix” things.

Similarly, respondents reported that their training in emergency medicine did not provide the necessary communication skills to have these types of end-of-life discussions with patients and family.

“I think a lot of us get a little bit blunt in the way we communicate things. And sometimes things need to be said a little bit differently with a little bit more care and comfort.”

Cultural

Given the multiethnic patient make-up of the county ED, respondents felt that their patient population may be unique form other EDs across the country. Some of the most obvious challenges are language barriers that may exist between patients/family and the ED physician. The sensitive nature of end-of-life conversations is difficult enough in English and compounded when attempted in a foreign language. Respondents mentioned that there was at least one bilingual speaker on the palliative care team, which made these conversations easier. However, given the limited availability of the team, the physicians often felt they had to take on these conversations themselves. Reliance on certified translators was an option but could be problematic because they are not trained in dealing with end-of-life issues.

In addition to linguistic barriers, respondents also reported additional cultural barriers including differing religious and spiritual beliefs and limited health literacy.

“Cultural beliefs are a major factor in death and dying. We particularly run into end-of-life issues because we may be dealing with somebody on life support or in a vegetative state. The family may totally understand or may totally fail to understand what is actually going on. On the other hand, here is this grieving family, who may not even believe this person is really dead, or that their spirit is in a lower order, their spirit trapped, or whatever, and we have to work with that.”

Disentangling cultural norms from differing patient and family desires can be a challenge in itself, as they are often entwined. Several physicians recognized this, describing the challenge of pleasing both the patient and the family, who sometimes have different needs. Physicians reported that often times, family members expect and request that the medical team do “everything possible” for the patient, often wanting heroic measures from the medical team to keep their family member alive. Physicians reported that in these cases when speaking with family members about end-of-life issues, their main goal is to prepare and educate while providing support. Chaplains were sometimes utilized under such circumstances.

The importance of patient informed decision making was described as the highest value. Respondents did not feel that patients were aware of their clinical status. Several respondents mentioned that “I don't feel like many of my end-stage patients understand their prognosis”—often due to lack of primary care, unreasonable expectations, or limited health literacy. In these cases, respondents still felt that patient informed decision making was of high importance and it was the medical team's job to ensure that patients make the best decisions possible.

Benefits

In spite of the challenges described in the interviews, respondents also spoke at length about the benefits of palliative care (Table 2). Respondents noted that, “seeing that our current health care system depends on the ED for access to the hospital and patients with advanced illness come to the ED for crisis care, palliative care is very important to provide even in the challenging setting of the ED.” In general, respondents spoke of these benefits in three distinct categories: patient, family, and provider benefits.

Table 2.

Benefits

Patients and families

Pain management

Quality of life

Family more prepared for death

Providers

Training can broaden perspective for emergency physicians in training

Increased job satisfaction

Patient and family benefits

The most identifiable benefits for patients were pain management and ensuring that the dying process was managed appropriately. Providing palliative care was felt to minimize suffering.

Physicians noted the challenges inherent in their mission as ED physicians trained to do “everything they can” to save a life, but they recognized the need take a step back and rethink the best care of a patient. Without previous discussions on the goals of care and advance directives the ED physician has to make the decision whether to prolong life. The palliative care team may not be able to respond rapidly to these cases when the need is within minutes. These split-second decisions have lasting impact.

Respondents felt that families benefited from the palliative care team by reviewing the treatment plan and helping to obtain needed resources such as medications, special equipment, and nursing care. One physician felt that family members should be considered a part of the health care team, “a provider for the patient.” Perhaps most important, according to our physician respondents, is that the counseling and consult of the palliative care team can help family members “face the reality of where they are” and help them come to terms with the terminal nature of their loved ones' diagnosis. One physician explained: “Letting people realize it's okay that their family members are very ill or dying and they just won't get better.”

Provider benefits

Respondents were unanimous in their assessment that providing palliative care does allow ED providers to feel better about a terminal situation. Being able to alleviate the pain and prepare patients and families for the final stage of an illness allowed providers to leave at the end of the day “thinking that I had a chance to guide a family through a very delicate decision and help a patient realize exactly what he wanted to do…that makes me feel very satisfied as a health care provider.”

When thinking about the challenges in providing palliative care in the ED setting, most of the respondents' replies also included how lucky they were to have a palliative care team, including physicians, social workers, and spiritual support, available to them. Although the palliative care team's availability is somewhat limited, respondents felt that having that resource was important, particularly in light of what they identified as their own limitations in providing that type of care (e.g., emergency training, limited time).

Emergency provider perspectives and recommendations

Lack of training and knowledge were common barriers noted, and it was generally felt that this material is important to integrate into emergency physicians curriculum and continuing medical education (CME). Didactic presentations through lectures, workshops, or presentations by members of the palliative care team were expressed as being an ideal training format. Emergency physicians identified important educational topics in their training such as accurately understanding palliative and hospice care, how to approach palliative care cases, tending to patients with chronic, non-life-threatening needs, and accurately identifying patients for whom palliative care is pertinent. Furthermore, some suggested incorporating direct patient care experience in the ED by allowing physicians to work through actual cases in collaboration with the palliative care team.

Many respondents were receptive to the idea of implementing a palliative care service within the ED and proposed suggestions for better integration into ED practice. To standardize the utilization of palliative care services, many physicians recommended the use of a diagnosis-driven approach by creating a checklist of criteria, such as life expectancy and disease state, that automatically alerts the emergency physician when a palliative care consult is appropriate.

This could also increase palliative care visibility in the ED and act as reminders to the emergency staff that referral to this service is an option. Using an automated process for identifying palliative care patients, this may take the value judgment about palliative care out of the hands of the ED physician and help decrease the associated stigma seen by peers.

Discussion

Palliative care is an important aspect of patient care in the ED. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. However, providing palliative care consultations can be time intensive and can require a certain level of sensitivity that is often at odds with the fast-paced environment of emergency medicine. Additionally, respondents pointed out that the provision of this kind of care may be more advantageous in a primary care setting given the primary care provider's ability to develop greater trust and rapport with patients and families. However, patients in the safety net will use the ED because access to primary care remains a significant challenge. These patients may present late in the course of illness and benefit from involvement of both the ED and palliative care teams.

ED physicians in our study appreciated being able to utilize the palliative care team. The limited availability of the palliative care team overnight and on weekends was a concern, although emergency providers acknowledged that they should be able to initiate basic palliative care skills during these times. This sense of responsibility and concern mirrors the results of another small study of emergency providers.¹³

In a call for research, education, and improved practice of palliative care in the ED, Chan recommends that researchers explore, among other issues, the barriers to delivering end-of-life care in the ED.¹⁴ He also recommends developing and testing educational programs and interventions to improve communication and incorporate palliative care precepts into emergency care. In addition, he recommends describing the various ethnic and cultural practices of patient and families when death is imminent or unexpected. The present study has laid the foundation for future exploration of these issues, as well as pointed to more specific areas of inquiry. For example, a better understanding of the different cultural perspectives on death and dying and how that can affect the provision of palliative and other end-of-life care would help inform palliative care programs and curricula.

Limitations to this study included not interviewing nonphysicians, particularly nurses who provide a great deal of clinical care in the ED. The setting of this particular study is not a typical ED, and emergency providers likely received more palliative care training and education than at other institutions. Similar studies should be conducted in other EDs to understand the issues of palliative care provision in other settings, such as community hospitals.

Although this study does show that there are barriers to providing palliative care in the ED, many opportunities exist. First, providing educational materials and courses that have been developed from the ED perspective Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-Emergency Medicine)¹⁵ should be included in ongoing CME. The need for palliative care specialists often occurs at night and on the weekends, when the palliative care team is often unavailable. Having a palliative care team that is responsive to this need will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

Footnotes

Acknowledgments

This study was funded by the Archstone Foundation.

Author Disclosure Statement

No competing financial interests exist.

Appendix

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