Monthly ED Palliative Pulse - March 2021

Clinical Pearl of the Month: Case Continued

70 year old man with metastatic colon cancer presents to the ED with pneumonia and respiratory distress.  He is obtunded and cannot give a history.  He has been unable to walk for months. You estimate his prognosis as likely just weeks to months.

As emergency medicine providers, we approach seriously ill patients with intent to quickly develop appropriate treatment plans that align with a patient’s values and work toward an achievable outcome.  To navigate this course effectively, consider using this communication framework (https://www.acep.org/palliative/newsroom/palliative-newsroom-articles/2020/download-the-em-code-status-guide/ ) that focuses on:

- 1) establishing trust through inquiry into the patient’s preceding functioning

- 2) understanding patient's values and priorities, and then

- 3) making a clear recommendation of which interventions would be realistically beneficial

Using this above framework, you begin a goals of care conversation with the patient's wife:

Doc: In the last few months, how did Mr. Jones spend his days?  What types of things activities did he do?

Wife: Well he couldn’t really walk, he mostly spent time in bed.  We would get him in a wheelchair for meals, bu mostly he was so tired so he’d sleep a lot in front of the TV.  He’d wake up when his grand kids were over but he’d be wiped out the whole next day.

Doc: Thank you. It sounds like he wasn't as active as he used to be, and I'm worried that he is even sicker now. If his time was becoming short, what is most important to him?  How would he most want to spend his time?

Wife: He just lights up with those grandkids. Rob hated being in the hospital, he asked me the last few days before he stopped speaking to not bring him here.  He was just so sick, I didn’t know what else to do.

Doc: If I understand what you are saying about Rob, it is he most valued spending time with his loved ones.  He would want to spend his last days surrounded by family at home, making sure they get all the support they need while he is made as comfortable as possible.

Wife: (tearful) yeah, that’s what he’d want

Doc: Ok, we can help make sure that his wishes are carried out.  To do so, I would recommend bringing a team of medical care to your home to support you and Rob, and ensure his comfort...

ED Palliative Program Highlight

Site: Mayo Clinic, FL. Academic/community, 34K ED visits/year. 8 palliative clinicians (7.5FTE).

Contact: Andrea Sharp MD, (EM-HPM); sharp.andrea@mayo.edu

Model: ED embedded palliative clinician, 10a-7p, one day a week. Triggered consult by EDMD based on diagnosis, palliative need, disposition driven.

Lessons Learned: 1) Keep it simple. 2) Less palliative clinicians in ED to improve continuity, recognition. 3) RN education/empowerment to recognize unmet palliative needs. 4) Do not alter ED flow, throughput. 4) Determine balance based on inpatient palliative resources. 5) Demonstrate institutional/clinician benefit.

Struggles: 1) Struggles with staffing, other responsibilities on ED days. 2) Equitable work distribution. 3) Who does follow up for ED consults? 4) How to increase ED embedded provider staffing.

Communication: Palliative clinician physically present in ED, only doing ED consults. Goal for EMR banner/notification based on trigger criteria.

Funding/Billing: Currently 100% Palliative Care funded (ED/Palliative MD using palliative time to staff ED embedded palliative consult service). May grow to shared departmental cost if successful. ACP billing to optimize RVU.

Next Steps: 1) Survey of ED provider satisfaction. 2) Develop ED specific palliative care consult note template. 3) Analyze outcomes metrics: ED LOS, ED dispo, ED to hospice transition, IP mortality, hospital readmissions, ED repeat visits, AD/POA documentation, hospitalization cost.

Research Article of the Month

Is the Emergency Department an Inappropriate Venue for Code Status Discussions? (sagepub.com)

This group from Iowa instituted a policy that ED providers should enter a code status order for all admitted patients. They hypothesized that since ED has traditionally emphasized life sustaining treatment that code status orders would be increasingly pushed towards FULL CODE. Instead they found: 98% compliance with ED code status orders and  ~4% increase in DNR orders placed in the ED, with no change in overall DNR orders during hospital admission unchanged.  

Announcements

Please join us for a mini lecture panel at SAEM 2021 with Dr. Kate Aberger, Dr. Tammie Quest, Dr. Elizabeth Clayborne, Dr. Sangeeta Lamba and Dr. David Wang.

Careers in Palliative Medicine With or Without Fellowship (Palliative Medicine Interest Group Sponsored)

Date: Friday May 14, 2021

Time: 1:30 PM-1:50 PM CT

Location: Online, SAEM 2021 virtual 

EM-Palliative trailblazers, please enroll here to be included in an expert speaker database- ACEP/SAEM Palliative Medicine Expertise Database

Congratulations to Dr. Marie-Carmelle Elie - emergency and palliative leader - for her appointment as chair of University of Alabama's EM department