Abstract
Dear Editor:
In the setting of the global novel coronavirus pandemic, the need for integrated palliative care (PC) in emergency departments (EDs) in times of crisis has become apparent. It is, therefore, critical that we collect the programs that have been trialed and lessons learned to codify a reproducible model for future times of need.
The discussion of how best to integrate PC into the emergency visit has been ongoing for over a decade. 1 No clear best practice model for care delivery has emerged and only a small number of effective programs can be found in the literature.2,3 In the setting of COVID-19, we developed an embedded PC model in our ED, elements of which may serve as an example to institutions facing similar challenges during this critical time.
The first COVID-19–positive patient arrived in our ED on March 10, 2020. As the disease burden worsened in our community, we recognized an urgent need to understand patient goals and values to provide goal-concordant care. Potential shortages of critical care resources placed an additional urgency on identifying patients who wished to avoid intensive life-sustaining treatment.
To develop a model of PC integration into the ED, twice weekly calls were initiated between senior PC leadership (chief of service), operational leads in PC, and an ED attending who had served as the PC liaison. Within a week, we had erected a model of ED PC that hinged on an embedded PC physician, a mechanism for rapid case identification, a clear plan to meet surge capacity, and COVID-19–specific conversation guides (Table 1).
Core Programmatic Elements of the COVID Emergency Department Palliative Care Program
ED, emergency department; PC, palliative care.
In the six weeks since the inception of this program, the team has formally consulted on 104 patients. Iterative changes have been made to the model to reflect challenges in case identification and the need to tailor the PC approach to the ED environment. For example, to streamline outreach to family members whose presence in the ED was limited by visitor restrictions, the team developed a workflow for shared telephone calls with the ED team. The ED clinicians initiated calls and provided the family a brief medical update, followed by a goals-of-care exploration by the PC consultant.
PC engagement in our ED has resulted in increased access for seriously ill ED patients to high-quality goal-concordant care. It has also supported ED frontline staff by having partners to have these challenging conversations. The feedback from the ED has been overwhelmingly positive, hinging on their appreciation for the “at the elbow” support as well as the consequent learning. It will be essential that, moving forward, we collect and study the variety of models that have organically emerged during this critical time to build a template that can be easily accessed and applied in the future.
With thanks,
The MGH emergency department palliative care team