Emergency Palliative Care: Acute Presentation of a Nonsurvivable Condition

Abstract

In this first segment of the emergency palliative care case series, we present a patient who arrives to the emergency department (ED) with signs of impending death in the setting of a newly diagnosed nonsurvivable condition. The patient has a history of chronic and serious illness including metastatic lung cancer, but her ED presentation is prompted by new symptoms of abdominal pain and diarrhea that are not immediately attributable to her known history and reflect the onset of a catastrophic process. Palliative care consultation is requested after surgery determines that that patient is not a candidate for surgical intervention. The palliative care provider plays an important role in supporting aggressive symptom management, elucidating goals of care, and rapidly facilitating disposition.

Introduction

Recently, there is an increasing awareness about the powerful role that subspeciality palliative care can play in the emergency department (ED). Traditionally, palliative care subspecialty providers have had little experience with ED care and may feel unfamiliar working with limited information in a resource-constrained environment. However, experiences during the COVID-19 pandemic have dramatically emphasized the potential for early intervention by palliative care subspecialists to change patient care trajectories.^1,2 This case series highlights the important care opportunity that exists at the intersection of subspecialty palliative care and emergency medicine.

Sharing clinical cases is a powerful and transformative means for heightening awareness and advancing care. Patient level details provide valuable insight into individual experiences and outcomes and, in turn, can help both emergency medicine and palliative care providers better appreciate each others' roles and opportunities.

As a starting point, it is critically important to realize that a wide range of ED patients can benefit from subspecialty palliative care intervention. Urgent palliative care needs are perhaps most readily apparent in patients who come into the ED with deterioration of their existing serious chronic illness. However, equally pressing needs may be present in patients with the sudden onset of a life-threatening condition or patients with an acute event or complication that heralds a pivotal moment in the trajectory of their underlying illness.^3,5

Within this case series, we present a diverse array of high-yield opportunities for subspecialty palliative care involvement in the ED. Through these clinical encounters, we emphasize several core principles that palliative care providers should consider in the ED setting.

The ED environment poses inherent challenges to addressing palliative care needs.^3–8 By nature, the ED is a busy, dynamic, and unpredictable place. In this setting, initial assessments may be skewed by the context in which a patient presents, and conflicting demands can significantly constrain time for evaluation and follow-up. These factors present obstacles to recognizing patients' palliative care needs and severely limit ED providers' ability to dedicate time at the bedside for symptom management and goals-of-care (GoC) discussions.

Acute care relies heavily on timely and focused consultant input.^4,6 Although ED providers most often assume full responsibility for the immediate resuscitation and diagnostic workup of a seriously ill patient, partnerships with subspecialty consultants play an important role in navigating the complexity, diagnostic uncertainty, and management challenges that exist within the ED population. In this setting, palliative care providers can serve a vital function by partnering with ED providers to optimize patient care and, as appropriate, helping to integrate subspecialty consultant input with patients' goals and priorities.

Disposition is paramount.⁴ Flow and efficiency in the ED depend heavily on rapid determination of patients' disposition. With progressively increasing overcrowding, ED providers must begin anticipating these plans from the first moment of assessment, including potential options for outpatient management and the level of inpatient care that may be required. Palliative care providers should be aware of this critical priority and support ED providers with clear guidance that may inform or impact patient disposition.

Prolonged patient boarding in the ED leads to numerous provider transitions. Extended stays in the ED are very challenging for patients and their families, as well as for the provider teams (ED, boarder, and inpatient) that care for them. When palliative care is engaged within the ED setting, there is an important opportunity to provide continuity to the inpatient setting. This involvement can enhance communication, comfort, and trust with significant implications for quality of care.

A 24/7 environment.^4,5 Since emergency care is not confined to the typical workday and is ongoing after hours and on weekends, providers in this setting are accustomed to adjusting to conditions and limitations imposed by the timing of a patient's presentation. Palliative care providers should consider how they can best support care within a 24-hr operation, including establishing a clear timeline of availability and optimizing the role of phone call recommendations.

Case Presentation and Palliative Care Consultation

A 71-year-old woman, “Eve Sullivan,” with a history of metastatic lung cancer, hypertension, chronic obstructive pulmonary disease, hepatitis C, opioid use disorder, and chronic kidney disease presents with her son to the ED with severe and unrelenting abdominal pain and diarrhea for two days. The patient's last chemotherapy treatment was the week before presentation. On arrival in the ED, Eve is noted to be awake and alert, but hypotensive. She is started on vasopressors (vasopressin and norepinephrine). Workup with imaging of the abdomen demonstrates extensive ischemia of the small bowel. Surgery consultants state that Eve is not a surgical candidate due to high risk of mortality during the procedure.

The hospital has a subspecialty palliative care team that is consulted to assist in the ED with GoC discussion, pain management, and disposition. In the area where the patient is located, the ED attending is managing 14 beds and 2 resuscitation rooms. All rooms in the ED are occupied and new patients are waiting approximately three to four hours in the ED waiting area. The ED team has not yet addressed patient's GoC.

Palliative Care Team Assessment and Initial Intervention

At the time of palliative care evaluation, Eve has been in the ED for three hours and it is Friday afternoon at 4 pm. The surgical team shares that the patient and her son have expressed that they “want everything” after being informed that surgery is not an option and that their recommendation is for a focus on pain control and end-of-life (EOL) planning.

Eve is fully interactive but uncomfortable and rates her abdominal pain at a level of 10/10. She has received a total of 2 mg intravenous hydromorphone since arrival in the ED with no appreciable effect on her pain. She shares that she has been taking Suboxone for several years and is not surprised that the hydromorphone has not helped. Eve expresses anxiety and distress as she asks for another medication that might help with her pain. The palliative care consultant feels that a next dose of hydromorphone of 4 mg IV is indicated. The ED nurse expresses hesitation.

Both the patient and her son share an understanding of her underlying illness and newly diagnosed complications, as well as the associated grave prognosis. In this context, Eve expresses that her most important priorities are to be comfortable (with relief from her severe pain) and also to see her boyfriend. During this discussion, Eve and her son share that they have been aware that her time is limited due to her cancer but did not expect such an abrupt change in her clinical status. The palliative care provider acknowledges the difficulty of this situation and validates the grief that both Eve and her son express. Ultimately, Eve and her son agree that she wants to pursue a comfort-focused approach to EOL. She is grateful for the offer of spiritual care support.

At this time, the ED attending stops by to say that the current team is going off shift in the next 30 minutes and they need a definitive plan for disposition of the patient—admit or discharge and which service will be caring for the patient—with the request that the palliative care clinician will help arrange. The palliative care team assesses disposition options, in light of persistent vasopressor requirements and active pain management issues with an expected prognosis of hours. Eve and her son agree that they would be terrified to have her die in her home and prioritize having her boyfriend come to see her at the hospital. There is no hospital-based palliative care unit.

Case Follow-Up/Outcome

Eve is admitted to general inpatient medicine where hospice care can be provided in any location (“scatter bed hospice”). The palliative care team clinician calls the contracted hospice team to evaluate, admits the patient, and serves as the admitting attending. Eve demonstrates decision-making capacity and is able to sign her own consent for hospice care. Boluses of fentanyl IV are initiated with the palliative care attending working closely with the nurse at the bedside to assist with serial dosing every 5–10 minutes and providing education and support to the ED nurse over 60 minutes, until the patient has some decrease in her pain (7/10).

At that point, an infusion of fentanyl is ordered and boluses are continued at the effective dose. Before transfer to the inpatient floor, vasopressors are stopped and a full transition to comfort-measures-only is initiated. The palliative care team leaves at 7:30 pm. Eve dies peacefully with family at her bedside approximately nine hours after her initial presentation to the ED.

Discussion

Palliative care engagement in this case had numerous important implications with respect to rapid GoC discussion and symptom management in the setting of a new acutely life-limiting complication of serious chronic illness. There were several fortuitous factors that contributed to the ability to provide expeditious goal-concordant care for this patient. First, the patient presented to a hospital with a palliative care team that was available for in-person consultation during weekday hours. Moreover, the ED and surgical teams rapidly identified palliative care needs for this patient leading to prompt consultation.

Although the fortunate timing and significant resources present in this case may be absent in other situations or settings, it is important to recognize the immense impact that PC support can have on the care and disposition of patients in the ED. As such, it is vital that palliative care providers seek opportunities to engage in the ED setting when possible and think creatively about how to best meet the needs that arise in this population.

This case highlights several important issues related to the role of palliative care consultants in the ED. These elements build upon the core principles that were outlined in the introduction and will be further addressed in subsequent cases in this series.

Do what is needed to care for patients in a busy ED:^2,4,6

The gravity of this patient's illness and the high risk of rapid deterioration required urgent attention with the demand for time-consuming tasks involving GoC discussion and aggressive symptom management. Although these needs were quickly recognized, the busy ED environment limited the ED providers' ability to dedicate time at the bedside for the intense level of care that this patient needed to facilitate decision making and determine next steps. The palliative care consultant, therefore, played an important role in taking charge of completing critical palliative care tasks, including GoC discussion, pain control, and disposition.

Given many competing demands, ED nurses may face challenges in providing rapid pain reassessment, thus, the palliative care provider was able to optimize pain management by remaining at the bedside for continual symptom monitoring and engaging the ED nursing staff at regular intervals to facilitate serial dosing. In this role, the palliative care provider also has an important opportunity to support ED nursing education in EOL symptom management.

Build upon input from consultants to manage complexity:⁴

The palliative care team was able to support the timely integration of specialist recommendations from the surgery team with the patient's preferences and goals. In this case, the patient and son were focused on optimizing comfort and, yet, this priority was initially obscured by a request for “everything.” Ultimately, it became clear that their interest in an aggressive approach primarily reflected a desire to ensure that her pain was addressed and was complicated by an acute grief response in the setting of a sudden and unanticipated change in her prognosis. Their wishes were quickly clarified in the context of a coordinated effort to address pain and to provide emotional support that facilitated decision making.

As a result, the palliative care clinician was able to assist with a change in disposition, such that rather than going to the ICU, this patient was transitioned to a hospice bed. In the event of more limited resources (e.g., no admitting privileges for palliative care and/or no hospice bed option in the hospital), the impact would still be significant as the patient could be admitted to a general medicine floor with palliative care consultation support.

Manage disposition when possible with particular awareness of pressures at ED shift change:^4,5

The ED has only one way to make room for waiting patients and those constantly arriving and, therefore, moving patients out of the ED (home or hospital) is of high priority. To optimize patient flow, ED clinicians have to start thinking about disposition as soon as they meet a patient. They are particularly sensitive to signing out cases at shift change without a clear plan and, thus, may lean on consultants to facilitate concrete disposition at these important moments of transition.

In this case, the engagement of the palliative care team had important implications for disposition that extended beyond the rapid GoC discussion that supported transition to comfort measures. Specifically, the palliative care team rapidly considered options for EOL care in the context of the patient's prognosis and preferences and, in turn, provided valuable leadership on the operational aspect of admission for hospice care.

Expect the need for flexibility in palliative care team hours:^4,7

Since the ED is a care location with unscheduled visits, patients will present for consultation at all hours. “Wait until Monday” or even a delay until the following day may not be appropriate. Although some logistical circumstances of this case eased the delivery of goal-concordant EOL care, this consult request was placed on a Friday afternoon near the end of a typical day and, thus, presented a stress for the team. For a patient with pressing palliative care needs in the context of impending death, rapid care is a priority for the ED and the palliative care service.

Addressing patient and family needs is time consuming and demands flexibility on the part of palliative care team. At the same time, this case also provides a valuable opportunity to think about how to optimize care during evening and overnight hours or in a community setting when palliative care providers are not available for rapid in-person consultation. Teams could consider telemedicine options and phone call-based recommendations, which can provide valuable support to the ED team and help to identify factors that may impact disposition in the context of rapid transitions. Moreover, supporting the acquisition of primary palliative care skills among ED providers is another important consideration.

Be a teacher:^4,7–9

The serial dosing of opioids is not routinely performed in the ED. In this case, the added complexity of a patient with an opioid use disorder history presents a considerable challenge. Skillfully and tactfully engaging team members, including referring providers, in these issues and teaching basic principles that support effective symptom management will be helpful. In this case, the palliative care provider recognized that the ED nurse did not have experience with rapid serial dosing of IV fentanyl in an EOL situation. The provider remained at the bedside to work side by side in ensuring optimal pain control for the patient while supporting skill development and comfort for the ED nurse.

Ultimately, the diagnosis of a new acutely life-limiting condition and the need for high-intensity care over the course of several hours represent key factors that herald the importance of early and timely palliative care involvement. In these circumstances, the patients face a dramatic change in their medical condition and prognosis without the support of their long-term providers because the acuity of illness precipitates emergency level care. Palliative care clinicians can provide crucial support to the ED and other specialty consultants in optimizing the care of these critical patients and their families by facilitating a rapid and coordinated approach to symptom management and decision making.

Footnotes

Acknowledgments

Emergency Palliative Care Working Group members include Emily L. Aaronson, MD, Ryan Baldeo, PA, Jason K. Bowman, MD, Paul DeSandre, MD, Kirsten G. Engel, MD, Brian Gacioch, MD, Corita Grudzen, MD, Vicki Jackson, MD, MPH, Maura Kennedy, MD, Sangeeta Lamba, MD, Shan W. Liu, MD, SD, Carter Neugarten, MD, Kei Ouchi, MD, MPH, Tammie E. Quest, MD, Janet S. Rico, CNP, PhD, MBA, Christine S. Ritchie, MD, MPH, David Wang, MD, Alex Zirulnik, MD.

Funding Information

No funding was received.

Author Disclosure Statement

No competing financial interests exist.

References

Lee

, Abrukin

, Flores

, et al. Early intervention of palliative care in the emergency department during the COVID-19 pandemic. JAMA Intern Med, 2020; 180(9):1252–1254; doi: 10.1001/jamainternmed.2020.2713.

Aaronson

, Petrillo

, Stoltenberg

, et al. The experience of emergency department providers with embedded palliative care during COVID. J Pain Symptom Manag, 2020; 60(5):e35–e43; doi: 10.1016/j.jpainsymman.2020.08.007.

Quest

TE.

Palliative Care in the Emergency Department, 1st Edition. Oxford University Press: New York, NY, USA; 2023.

Wang

, Kuntz

, Aberger

, DeSandre

. Top ten tips palliative care clinicians should know about caring for patients in the emergency department. J Palliat Med, 2019; 22(12):1597–1602; doi: 10.1089/jpm.2019.0251.

Wang

. Beyond code status: Palliative care begins in the emergency department. Ann Emerg Med, 2017; 69(4):437–443; doi: 10.1016/j.annemergmed.2016.10.027.

Argintaru

, Quinn

, Chartier

, et al. Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents. CJEM, 2019; 21(2):211–218; doi: 10.1017/cem.2018.371.

DeSandre

, Quest

, (eds). Palliative Aspects of Emergency Care, 1st Edition. Oxford University Press: New York, NY, USA; 2013.

Aberger

, Wang

, (eds). Palliative Skills for Frontline Clinicians, 1st Edition. Springer Nature: Switzerland; 2020.

Wang

, Creel-Bulos

. A Systematic Approach to Comfort Care Transitions in the Emergency Department. J Emerg Med, 2019; 56(3):267–274; doi: 10.1016/j.jemermed.2018.10.027.