A few months ago, I walked into work on a late-night shift. One of the nurse practitioners came up to me and said, "There's someone you need to see right away."
The patient was a woman of about 60, and it was clear that she was critically ill. According to her husband, she'd been diagnosed with cancer six months ago. It had metastasized throughout her body. Her oncology team made several referrals. In fact, the couple had spent the last two days traveling to see a specialist in another city. Signs pointed to a perforated abdominal organ — probably caused by one of her metastases.
Maximal intervention would require intubation, placement of a central line and a rush to the operating room for an emergency laparotomy. And even then, I doubted she'd survive.
"We've called respiratory therapy. Are you going to intubate her? Should I get the levophed?" the nurses asked.
I had a choice to make.
The Role of Palliative Care in the ED
As emergency physicians, we're trained to make quick decisions that save lives. This usually means providing the most aggressive treatment available. But as our experience and clinical judgment grow, we realize that this approach isn't necessarily best for every patient.
In recent years, there's been a marked shift toward providing palliative care for critically ill patients in the emergency department. This trend is driven in part by a need for cost containment — 28 percent of Medicare spending is on patients in the last six months of life.
But even more importantly, our profession is starting to realize that aggressive treatment is not always best for patients.
Emergency physicians and nurses often know when they're providing care that is (for lack of a better word) futile. "Wow, if it were me, I'd just want them to let me go," we say when we're out of earshot of patients.
Yet we often turn around and walk into patients' rooms assuming they want us to do everything in our power.
This belief constrains us, but is it grounded in reality? Sure, many patients will accept another surgery, another ICU stay and another round of rehab if we recommend it. But when you take time to talk with patients, a different picture emerges. Often they just want their pain controlled so they can go home. Much of the time, both they and their families understand where they are in the continuum of life, and sometimes they would rather just be given the honest truth.
So why aren't conversations about palliative care routine in the ED? For one thing, not all emergency physicians feel at home in that role. We're far more comfortable intervening aggressively than talking about prognosis and helping families make decisions.
Also, these conversations take time. And we're already working under pressure. In a practical sense, it's often far easier to admit the patient and allow the hospitalist (who's better trained in this area) to discuss goals of treatment.
But preliminary research suggests that a palliative care consult in the ED (as opposed to later in the hospital) can have real benefits for patients, including significantly decreased length of stay and fewer readmissions.
At a personal level, I think inquiring about the patient's wishes and preferences is both respectful and empowering. Do they know how sick they are? How far do they want care to go? How do they feel about invasive procedures that may not prolong or improve their lives? Want do they want their final days or hours to look like?
It's not easy, and I certainly don't get the words right every time. But I will say that when they happen, these conversations are almost always very well received. In fact, they're some of the most satisfying patient and family interactions I've had as a physician.
A Good Good-Bye
To illustrate how palliative care can make a difference in the ED, let's return to my patient with late-stage cancer and abdominal pain.
After explaining to her what could be done — intubation, central line, surgery and so on — I took a deep breath and said, "You realize how sick you are. We can do all these things, and in my best judgment, I don't think that they're going to prolong your life or improve it."
She looked at me and said, "You're right. I know. Thank you for telling me that. None of my other doctors would tell me that."
Her husband pulled me aside. "I knew it was coming to this," he said. "I didn't know when or how quickly, but she's been declining for a couple of months. And we kept going from doctor to doctor looking for a cure, because each doctor sent us to another doctor."
Then he said, "What can you do to help her feel better right now?"
I assured him that if they both agreed, we could make his wife very comfortable and give her excellent care.
So after some further conversation, the husband got on the phone and called friends and family members who were in the area. Within an hour, about ten people came to the emergency department to see the patient and say goodbye to her.
And within about two hours, she passed away.
Afterward, the husband thanked me. He was grateful that we hadn't put his wife through the stress of aggressive resuscitation and surgery. He also thanked me for telling the truth and not holding out false hope.
Could aggressive care have benefited this patient? In my judgment, probably not. She would likely have died in the OR or the next day. She wouldn't have had her family around her in her final hours. The outcome would have been far less satisfying for everyone involved.
For me, she was a poignant example of why emergency departments need to invest in palliative care training and pathways. Delivering excellent end-of-life care requires a major shift in our ED thinking and culture. But the benefits for our patients are emphatically worth the effort.