Palliative Care in the Emergency Room: An Oxymoron or a Natural Partnership?

I have often likened the position of the emergency physician to that of a goalkeeper: No matter what, do not let that ball pass you into the net. Perhaps this is my metaphor because of my long history as a goalkeeper in soccer. When the ball would get by, I could not help but feel worthless with no one to blame but myself. As an emergency physician, our job is similarly that of a sentry, on watch for death, discerning its mechanism and taking it down without hesitation.

But life and death in the emergency department is, of course, not as simple as my history of sports. People come through our doors at rapid speed, with the full range of chief complaints and prognoses. As our population ages and our life quantity is extended, our life quality has been much more difficult to prolong. Increasingly, we are extending lives with algorithms of aggressive therapy, but we are doing this without also establishing clear and humanistic protocols for medical futility. It is our role as physicians to educate society broadly and on an individual basis on what is involved in “full code,” and that it often precludes full life to its natural end.

Whereas reacting reflexively is the role of the goalkeeper, the role of the emergency physician is different. Emergency practice at its best includes the skills of listening, watching, distilling hard and soft data, and educating our patients and their families about their disease. It involves helping patients and families on what they want, even if they do not know what that is. Just like bringing up smoking cessation to the 50-pack-per-year patient on every visit, or condoms to the patient engaged in high risk sex, our job is to bring up the uncomfortable.

All of the emergency physicians I know have intubated or resuscitated patients that had no hope for cure or even conscious life. Just as we feel awful when a patient dies while in our care, many of us also mourn resuscitations that have left people alive without meaningful life. In the emergency department, many of us recognize the importance of these open discussions that would allow a natural death. We also recognize the intrinsic barriers: the lack of time, the lack of resources, the fear of litigation, our own lack of education about proxies and code status definitions, the lack of code status sharing between institutions, and perhaps most importantly, our own emotional difficulty with seeing palliative care as giving up instead of treatment, treatment without the goal of cure. Palliate: To reduce the violence of disease, to ease without cure. Perhaps the ball still crosses the goal, but perhaps more gently, more consciously, with eyes open, words spoken, and with no one to blame.