Palliative Care Provision in the Emergency Department: Barriers Reported by Emergency Physicians

Abstract

Background:

There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated.

Objective:

To elicit the ED physicians' perceived barriers to provision of PC in the ED.

Methods:

ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers).

Results:

Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation.

Conclusion:

We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.

Introduction

The Emergency Department (ED) cares for those who suffer from serious, chronic, life-limiting illnesses as well as the acutely ill.^1–5 Traditional emergency medicine (EM) training however, focuses mainly on resuscitation and stabilization of the acutely ill or injured.⁶ Optimal care provision for both the seriously ill from chronic disease and the acutely ill patient in extremis involves integrating palliative care (PC) principles into ED practice.^4–5,7,8 PC provision in the ED may be classified as generalist-level or specialist-level of care.^3,13–15 Generalist-level PC is provided by the ED clinician, e.g., management of malignancy-related pain. Specialist-level PC is the traditional consultation model where the ED physician initiates a PC consultation for more complex issues, for example nonoperative management of a malignant bowel obstruction.

Though experts in both emergency and palliative medicine recognize the need for increased collaboration, the ED poses challenges to PC integration. Studies suggest that ED clinicians trained for resuscitative, life-saving care may not consider PC as part of their overall mission or in their scope of practice.^9,10 Since PC exposure/integration may be limited and variable in EM residency training, it is feasible that ED clinicians may feel unprepared to provide PC at a generalist level and also not consider specialist-level consultation for eligible clinical presentations.⁶ However, unlike other disciplines, specific barriers to PC provision as identified by the practicing ED clinicians have yet to be fully described.^20–23 Therefore, the objective of our study was to elicit the barriers to provision of PC in the ED as perceived by ED physicians and trainees.

Methods

Study design and population

We conducted a convenience sample survey of EM residents and faculty in an urban, tertiary teaching hospital with approximately 100,000 patient ED visits per year. The site has a four-year EM residency program with six residents per year. The faculty comprises EM residency trained, EM board certified/eligible physicians. The hospital has a palliative team comprised of two advance practice nurses, two masters trained family support/bereavement support specialists, as well as social workers and volunteer clergy, available on an ad hoc basis.

Survey content, administration, and analysis

The survey domains were developed from a comprehensive EM PC literature review^13–15 (see Table 1). The panel consisted of ED physicians (SL, SS), faculty with PC research experience (SC, SL) and dual EM and palliative medicine certification (SL), and a palliative team advance care nurse practitioner. The questions were piloted with input from a small group of the EM faculty and the final survey determined by author consensus. We consider both residents and faculty as a group, since prior study has shown that there is no significant, consistent improvement in self-reported PC domain-related scores (for knowledge, training, comfort, and competence) as the training level progresses.¹³ In fact, comparisons between ED residents and faculty reveal that scores frequently decline for faculty, possibly reflecting greater humility among those who held the ultimate responsibility for patient care.⁶ All EM residents/faculty were anonymously surveyed from June 2010 to October 2011. The project was approved by the institutional review board of the University of Medicine and Dentistry of New Jersey–New Jersey Medical School.

Table 1.

Survey to Identify Emergency Department Physician-Perceived Barriers to Palliative Care

The following questionnaire is being used to identify some barriers that providers may face in delivery of palliative care in the ED. Please rate the extent to which you agree or disagree with following these statements. Circle the appropriate number using the scale below. We greatly appreciate your feedback!
	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1. Access to complete patient records would allow me to better provide palliative care in the ED.	1	2	3	4	5
2. I am not comfortable providing a prognosis for patients in the ED.	1	2	3	4	5
3. Palliative care is better provided in an environment other than the ED, which is often loud/overcrowded.	1	2	3	4	5
4. A 24 hr palliative care consult team would allow me to better provide palliative care in the ED.	1	2	3	4	5
5. I have sufficient time to communicate with patients/families with regards to their palliative care needs.	1	2	3	4	5
6. Working in a less litigious environment would encourage me to provide palliative care in the ED.	1	2	3	4	5
7. The ED is a place to provide resuscitations and aggressive medical care, not palliative care.	1	2	3	4	5
8. Regardless of patient presentation, providing palliative care is one of the lowest priorities for me in ED.	1	2	3	4	5
9. I find discussions to elicit patient goals for a DNR/DNI to be emotionally challenging.	1	2	3	4	5
10. My personal beliefs usually conflict with the concept of DNR/DNI.	1	2	3	4	5
11. I think of palliative care only for those patients in for whom I can offer no treatment to save their lives.	1	2	3	4	5
12. I have had adequate education/training in palliative care.	1	2	3	4	5
13. I have had adequate education/training in pain management.	1	2	3	4	5
14. Palliative care approach conflicts with concept of life-prolonging treatment.	1	2	3	4	5
15. I have had adequate training/education in communicating bad news, including death.	1	2	3	4	5
16. I have had adequate training/education in communicating and obtaining advance directives.	1	2	3	4	5
17. Since it is routinely difficult to contact a patient's family, this interferes with palliative care in the ED.	1	2	3	4	5
18. Difficulty in contacting the palliative care team interferes with providing palliative care in the ED.	1	2	3	4	5
19. Communication difficulties with the outside providers interfere with palliative care in the ED.	1	2	3	4	5
20. The time it takes to reconsider aggressive medical interventions interferes with palliative care in ED.	1	2	3	4	5
21. Conflict between family and patient health care wishes interferes with palliative care in the ED.	1	2	3	4	5
22. I am comfortable managing terminal symptoms like severe dyspnea in patients with a DNR/DNI without intubation or ventilator support.	1	2	3	4	5
23. I am comfortable managing the removal of a patient from a ventilator/life support if that is the family/patient's wish.	1	2	3	4	5

In which of the following scenarios would you consider/call a palliative care team consult? Please check ALL choices that apply:

□ Massive intracranial hemorrhage

□ Traumatic arrest

□ Patient in ED for 3rd episode of missed dialysis in 6 months

□ Admission from a long-term care facility (due to dementia)

□ Patient over the age of 85 years with new-onset diabetes

□ Admission (second in 3 months) for COPD exacerbation

□ Admission (second in 3 months) for CHF exacerbation

□ Child with cerebral palsy and bilateral pneumonia

□ Cirrhosis with intractable ascites (in ED for 3rd tap)

□ Septic shock

□ Conflict between family members regarding code status

□ Metastatic cancer on chemotherapy

□ Metastatic cancer not on chemotherapy

□ Cancer patient in ED with pain medication issues

□ Hospice patient in ED due to respiratory distress

Please tell us about yourself:

Age: _____ Gender: □ Male□ □ Female Ethnicity: ________________ Religion: _______________

Physician □ Years of clinical experience _____ Resident: PGY1 □ PGY2 □ PGY3 □ PGY4 □

Comments: ____________________________________________________________________________________________________________________________________

The questionnaires were distributed during weekly EM mandatory conferences. A checklist ensured that each participant was handed the survey once. The returned (anonymous) questionnaires were randomly assigned a number and corresponding data entered into an Excel spreadsheet. Every third survey was audited (SL) to ensure accuracy of data entry.

Participants were asked to rank 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of physician-perceived barriers to PC provision: (1) education and training in PC, (2) relational or communication-related/collaboration issues, (3) ED setting and environment, and (4) personal beliefs. Respondents were also asked if they would initiate a palliative consultation for clinical scenarios derived from established, commonly used inpatient PC consult trigger criteria.¹¹ Descriptive statistics are provided.

Results

Sixty-seven percent (30/45) of eligible participants completed the survey: 23 residents and 7 faculty (n=45; 30 residents including incumbent/incoming class and 15 ED faculty). Average age of respondents was 31 years and 52% (15/29) were male. Respondents identified themselves as Caucasian (15/26, 58%) African American (3/16, 11%), Asian (3/26, 11%), and Hispanic (3/26, 11%). Respondents identified two main barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2) (see Figure 1). Other listed domain barriers (in descending order of importance) were communication-related issues (mean 3.3), the ED environment (mean 2.8), education and training (mean 2.7), and personal beliefs (mean 2.5).

FIG. 1.

Emergency physician perceived barriers to palliative care in the emergency department (1=strongly disagree, 3=neutral, 5=strongly agree).

The majority of ED clinicians would initiate a palliative consultation for a hospice patient in respiratory distress, massive intracranial hemorrhage, sudden traumatic arrest, and metastatic cancer (see table). However, ED clinicians rarely considered a PC consultation for traditionally used inpatient consult triggers such as frequent readmits for organ failure (cirrhosis, CHF, and COPD exacerbations).

Table.

Patient Case Scenarios That ‘Trigger’ a Palliative Consult by the Emergency Physician

Patient scenario	Number of respondents who would initiate a palliative care team consult n=30 (%)
Patient under hospice care in respiratory distress	29 (97)
Metastatic cancer	25 (83)
Massive intracranial hemorrhage	22 (73)
Sudden traumatic arrest death	22 (73)
Septic shock	16 (53)
Cancer patient in ED for pain medication issues	15 (50)
Long-term care facility resident (dementia) re-admission	10 (33)
Cirrhosis with severe intractable ascites (multiple ED visits)	4 (13)
Readmission (second in 3 months) for COPD exacerbation	3 (10)
Readmission (second in 3 months) for CHF exacerbation	3 (10)
Repeated recent ED visits for missed dialysis in renal failure	2 (7)

ED, emergency department; CPR, cardiopulmonary resuscitation; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure.

Discussion

A growing number of seriously ill patients present to the ED for acute crisis events related to the underlying progressive illness and/or the terminal crisis event in their disease trajectory.^1–5,9–12 The ED usually sets the stage for future inpatient care, as life prolonging measures and disposition to intensive care setting is often made in these early hours.^1,7 Though early goals-of-care discussions may help tailor optimal care plans that are based on patient preferences, often they do not occur in the ED.⁷ Despite a call for collaboration from both disciplines of emergency and palliative medicine, many barriers to integration of and provision of PC in the ED exist. Some studies postulate the following as barriers to PC provision in the ED: chaotic setting, time constraints, emphasis on throughput disposition, and lack of prior established relationships with patients and families.^{2,3,5,9,10,13} However, unlike other disciplines, studies have yet to explore which specific factors are perceived as barriers by ED physicians.^20–23

The findings of our survey are that EM physicians perceive two major barriers to ED PC provision: (1) lack of access to complete medical records and (2) lack of 24/7 availability of the palliative team. Prognostication with limited access to medical records while caring for a rapidly deteriorating patient presents a significant challenge in the ED.¹³ Prognostication is an acknowledged barrier even in settings (e.g., critical care, pediatrics) with better access to medical records.^20,22 An end-of-life trajectory in ED is often only able to be identified retrospectively.¹⁶ Many ED physicians report increased stress or conflict when prognosis and end-of-life directives are unclear and most default to providing life prolonging care in such cases.⁹ Not surprisingly, studies find that most ED-initiated palliative consultations involve imminently dying patients who often die in the ED or soon after.¹⁷ Therefore, the specialist-level support requested by the ED is likely to be urgent emergent.^17,18 Since these are evolving, real-time needs, it is not surprising that ED physicians likely perceive the lack of inhouse palliative team availability during off-hours and weekends a barrier to provision of specialist-level PC in the ED. Prior studies also suggest lack of familiarity with the PC team as a barrier to PC.²³

When asked which case scenarios would prompt a palliative consultation, most ED physicians agreed that they would consult for a respiratory distress patient under hospice care. This may be due to the fact that hospice as a care system may not be familiar to ED clinicians¹⁹ or that EM physicians may face conflict and find the switch to comfort-based, end-of-life care challenging.⁹ The majority would initiate a PC consultation for metastatic cancer, traumatic arrest, and massive intracranial bleed (where poor terminal prognosis or imminent death is certain). However, chronic/organ-failure scenarios (dementia, CHF, COPD) were very rarely considered as reasons to initiate specialist-level consultation. Though organ failure related readmits are listed as common inpatient consultation triggers, ED physicians may find the prognosis in such cases too uncertain or difficult to ascertain, or stabilization of the acute deterioration may take priority over ‘big picture’ considerations. It is also feasible that ED physicians still equate PC with end-of-life care. Therefore, there is a need to evaluate and adopt support tools for ED palliative consultations and reliable ED screening methods that help with early identification of patients in need of PC services.¹⁹ At an institutional level, we suggest (1) use of a similar survey to identify local physician-related barriers and (2) partnership with the ED to establish concrete, easily recognizable ED triggers such as, “Is this patient likely to die during this admission?”

Limitations

This is a small convenience sample, institution-specific assessment of barriers to PC; and findings may not be generalizable, especially in well-developed PC programs with inpatient palliative units. The survey was an investigator developed instrument; thus its reliability and validity are unknown. We analyze trainee and faculty responses as a group,⁶ and sample size limits further meaningful comparisons between respondents.

Conclusion

Our survey identifies two main ED physician-perceived barriers to PC provision in the ED setting: the lack of 24/7 availability of a palliative team and lack of access to medical records. When initiating a PC consultation, EM physicians may not consider similar triggers to those traditionally established for the inpatient palliative consult models. Further, larger studies are needed to define ED-specific triggers that may help streamline PC consultations.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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