Thursday, June 25, 2009

Challenges for Emergency Departments: Incorporating Palliative and Geriatric Care

The most recent issue of Annals of Emergency Medicine included several interesting articles about the role of geriatrics and palliative care in the emergency department. In the spirit of full disclosure, I wrote one of the articles in collaboration with a group from Harvard, and the intersection of geriatrics, palliative medicine, and emergency department care is a special interest of mine. My study used focus groups with emergency medicine providers (doctors, nurses, social workers, ED technicians) to explore perspectives of palliative care in the emergency department. We found emergency medicine providers were surprised to find that palliative care could be delivered simultaneously with life-prolonging care, that communication with outpatient providers was a major concern, and that providers sought additional skills training in communication and pain and symptom management. We described several poignant stories of emergency care gone awry, due to failures of communication, conflicts between written advance directives and surrogate wishes for care, and concerns about litigation. On a personal note, as someone standing behind the one way mirror to the focus group room, I was astounded by the conviction with which these emergency providers felt palliative concerns required greater attention in the ED.

In related articles, Dr. Tammie Quest and Dr. Robert Zalenski articulate the case for palliative care training by emergency medicine providers (the American Board of Medical Subspecialties and American Board of Emergency Medicine recognizes palliative medicine as a subspecialty of emergency medicine). Dr. Zalenski eloquently states:

"Hospice and palliative medicine provides a refreshing substitute to acceptable medical practice, which has assumed a programmed robotic stance to diagnose and cure all illnesses. This discipline returns channels for compassionate action to the increasingly depersonalized practice of medicine. In a health culture intoxicated by the ease of access to advanced diagnostic technology, the discipline of palliative care allows the emergency physician to rightfully curb the use of tests and interventions that prolong suffering but not life. It can help prevent the initiation and continuation of nonbeneficial treatments or those contrary to patients’ wishes or goals of care. While respecting patients and their families, palliative emergency medicine can provide comforting solutions and acceptable alternatives in an already tense environment. Saving a person and his family from avoidable suffering and unwanted, expensive, burdensome treatment while providing comfort and celebrating a dignified death will one day be as welcomed by the emergency physician as saving a life through aggressive management is currently."



I think he's on absolutely the right track here, although the discussion is focused slightly too heavily toward care of the dying, and more inclusion of the role of palliative care in the management of patients with serious and chronic conditions would have been helpful.

Picking up the thread of caring for adults with chronic conditions, a news and perspective piece by Eric Berger in the same issue discusses the creation of geriatric emergency departments, focusing on one pilot project at Holy Cross Hospital in Maryland. The theoretical foundation for the creation of these specialized centers is built around the same premise used to establish pediatric emergency departments: just as children are not young adults, geriatric patients are not just old adults. These geriatric emergency departments contain structural and clinical changes designed specifically to meet the needs of elders. Building on the success of Acute Care of the Elderly (ACE) units, these emergency facilities reduce noise such as overhead pages, softer bedding, comfortable chairs, and quiet spaces for family conferences. Staff screen patients for depression, cognitive impairment, and fall risk, and a social worker or nurse practitioner follows up with at risk patients. Communication with outpatient providers is emphasized. The goals, as I gather from the article, are to prevent iatrogenic complications of care such as delirium, identify patients at risk for repeat visits and manage their care, and attract seniors seeking care to the hospital. These goals directly inform the financial model, with the first two goals aimed at cost avoidance, and the final goal aimed at increasing revenue by attracting elderly patients, who are more likely to be insured and admitted to the hospital compared to younger adults. I am less comfortable with this final point as a goal of the hospital - posited as a win win situation for elders and hospitals in the article - as greater care for one group invariably leads to less care for others, in this case, indigent patients. However, the idea of specialized emergency centers for care makes sense, just as ACE units make sense for care of hospitalized elders. The research to establish the efficacy, both in terms of health outcomes and the financial model for sustainability, has yet to be conducted. R01 anyone???

The thing that interests me about these articles gets at the core reason for starting this blog in the first place: the overlap of geriatrics and palliative care. We need a greater sense of what it means to address the palliative needs of frail elders with complex and chronic conditions. This issue is fundamental to our country, as the twin trends of the aging population and rising health care costs conspire to bankrupt our system. Palliative care and geriatrics, unlike many specialties whose financial models rest on increasing revenue through procedures, are founded in part on models of cost containment and avoidance. These aims are accomplished through, not ins spite of, improved quality of care for older adults with serious illness. The emergency department is one area of spiraling costs for elders, and as one physicians argues in the news piece, "almost textbook cases for how you should not deal with seniors." One could make the same argument about the emergency department as a setting for patients with palliative concerns. How can we integrate the vast experience and strengths of palliative and geriatric medicine in setting such as the emergency department to meet the needs of older adults with serious illness, and contain costs? What are your thoughts? We created this blog for this purpose - as an living and growing resource, social network, and forum for discussion of these critical and exciting issues.

3 comments:

ken covinsky said...

Great post Alex!

I think one issue your article and the whole series of articles illustrated is the importance of delinking palliative care and end of life care in the ED. It seems a major issue here is that many older patients are not presenting to the ED for end of life care--yet the drivers of what brought them to the ED in the first place---symptomatic distress, caregiver distress, declining functional represent issues that stand at the intersection of Geriatrics and Palliative Care. It will be important for all of our disciplines to think about how a more gerocentric ED would provide this sort of care.

In addition to this nice series of articles in the Annals of Emergency Medicine, Hwang and Morrison have also provided some interesting ideas (Hwang U, Morrison RS. The Geriatric Emergency Department; 2007; J Am Geriatr Soc; 55; 1873-1876

Alex Smith said...

An excellent observation Ken. Delinking palliative and end of life care is difficult for ED providers, who viewed palliative care as something exclusively for patients who are dying in our study. But your point is right on target -- concerns that bring many older patients to the ED, many of whom are not actively dying, are at the intersection between palliative care and geriatrics.

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