Background
Patients enrolled in hospice programs will occasionally be transported to the emergency department. Emergency medicine training focuses on life-prolonging measures and may fail to address hospice as a system of care. This Fast Fact provides information for clinicians practicing in emergency departments on management issues when a hospice patient arrives. Fast Fact #247 discusses initiating hospice care from the emergency department.
Why do Hospice Patients come to the Emergency Department?
Emergency department providers should never assume that arrival in the emergency department equates a desire for aggressive/life-prolonging treatment. Even when a patient/family requests such services, an assessment is needed to understand the concerns that prompted a shift in care goals. Frequently such requests arise from fear about the dying process or guilt about prior medical decisions to limit life-prolonging treatments. Common triggers for an emergency department visit include:
• Stress/inability to cope with impending loss of life. This may be expressed as a request to start a life-prolonging treatment previously used and discontinued (e.g., chemotherapy) or never begun (e.g., renal dialysis).
• Poor symptom control.
• Malfunction/loss of a support device such as a gastrostomy tube.
• Failure of the hospice program to provide timely patient support and communication.
Management Guidelines
1. Notify hospice staff as soon as possible. Under the Medicare Hospice Benefit, hospice agencies are legally/financially responsible for the patient's plan of care and all medical costs related to the terminal illness. See Fast Facts # 82, 87, and 90.
2. Determine the trigger for the emergency department visit, pay attention to not only the distressing signs and symptoms but also the emotional and psychosocial issues. Involve social service and chaplaincy personnel early if needs are identified. Contact the palliative care team for consultative advice if needed.
3. Treat distressing symptoms. See Fast Facts for specific symptom treatment guidelines.
4. If deterioration is imminent and rapid decisions are needed regarding the use of life-sustaining treatments (e.g., intubation for respiratory failure) a focused discussion around goals of care must occur in the emergency department
• Determine the legal decision maker if available and review any completed advance directives.
• Complete a rapid goals of care discussion (see Fast Facts #223-227).
• Make recommendations. For example, “According to what you want for [the patient], I would/would not recommend….”
5. If the patient is actively dying (see Fast Fact #3) assess for cultural/spiritual needs; assure privacy and endeavor to identify if there are any preferred locations a patient can be safely transferred to for the dying process (e.g., back home, to a private hospital room).
6. Laboratory tests/diagnostics should be limited or withheld until discussion with the patient's hospice care team. Testing should be based on patient-defined goals of care. Generally, low burden, noninvasive methods that may reveal reversible pathology or clarify prognosis should be used first.
7. Therapeutic modalities should be based on patient-defined goals of care rather than automatic “emergency department indications” (e.g., antibiotics for pneumonia should only be used if they meet a patient or surrogate defined goal of care).
8. Disposition should be planned after discussion with hospice staff based on the patient's goals. Returning home or a direct admission to an inpatient hospice facility may be the best disposition rather than hospital admission. At times, hospices can arrange 24-hour professional support in the home for patients with difficult to manage symptoms who wish to remain home (“continuous care”—see Fast Fact #87).
9. Notify the inpatient palliative care service if the patient is to be admitted to the hospital. Hospice agencies may revoke a patient's enrollment in hospice care if care goals have changed, or may continue a patient under hospice care during an admission for palliation (see Fast Fact #87).
Summary
Patient-centered care for hospice patients may be enhanced by emergency medicine clinicians who acquire skills to quickly adapt to a supportive role in the care of a terminally ill patient. Recognizing common triggers for the emergency department visit, using a multidisciplinary approach with early involvement of hospice, social services, and palliative team consults may assist in providing optimal care for emergency department patients under hospice care.
