Palliative Pulse - January 2025

Table of Contents:

• Chair’s Corner
• Clinical Pearl
• Education/Training Resources
• ED Palliative Program Highlight
• Research Articles of the Month
• Announcements
• ACEP Council 2024
• Leaders in Transition
• References

Chair’s Corner

Dear ACEP Palliative Section Members,

It was great to see those of you who could attend ACEP 2024 in person and I appreciated the engaging section meeting and the lively section craw.  We had a great turnout during the section crawl with ACEP attendees from around the nation stopping by the table to ask questions and find out more about the mission of our section and the expanding awareness of the role of palliative care in emergency medicine. 

I would like to highlight the need for a member of our section to consider applying for a position on the Education Committee.  ACEP conference content is so broad as a result of our specialty, that having a voice on this committee is an essential step to ensuring that high quality content related to our specialty is getting showcased nationally.  See the announcement below for more information.  Also, if you are considering a ACEP didactic submission and did not submit to the ACEP CME track program, you can still submit content to the ACEP Non-CME content track by June 1, 2025. For more information, please go here. Thank you for all you do to make our specialty great and looking forward to our next section meeting Thursday March 6, 2025, at 2pm EST/1pm CST.

Justin Brooten, MD, FACEP
Chair, ACEP Palliative Medicine Section

Clinical Pearl

A 75-year-old hospice patient with end-stage heart failure presents to the ED with worsening shortness of breath. The family is distraught and requests “everything to be done,” including intubation. You are not sure what to do—how do you effectively manage this situation while respecting patient’s wishes?

Why Do Hospice Patients Come to the ED?

Hospice patients often visit the ED for a variety of reasons, but arrival does not always signal a desire for aggressive or life-prolonging treatment. Requests for such care may arise from fear of the dying process, caregiver guilt, or distress. Common triggers include:

• Poor symptom control (pain, dyspnea, GI issues).
• Malfunction of support devices (e.g., gastrostomy tube).
• Falls or unrelated injuries.
• Caregiver stress or distress.
• Inability to cope with impending death.
• Hospice program delays in support or communication.

Management Guidelines

1. Notify hospice staff early, as they oversee care under the Medicare Hospice Benefit and hospice would likely be revoked.
2. Identify the visit’s trigger, addressing both physical and emotional needs. Engage social services, chaplaincy, or palliative care if needed.
3. Treat distressing symptoms promptly based on goals of care.
4. Determine legal decision-maker and review advance directives.
5. Conduct a rapid goals of care discussion. Example: “Based on what you’ve shared, I would/would not recommend…”
6. Avoid unnecessary tests/interventions unless aligned with the patient’s goals. Be especially considerate with invasive interventions that can cause suffering.
7. Plan disposition with hospice: options may include returning home, inpatient hospice, or 24-hour continuous care at home for symptom management.
8. Involve palliative care for hospital admissions if needed.

Key Point: ED clinicians can improve patient-centered care by recognizing hospice patients’ needs, focusing on comfort, and collaborating with hospice and multi-disciplinary teams to ensure care aligns with the patient’s goals.

Education/Training Resources

• EUSEM e-Course
  • Course Description:
    This e-course covers core palliative care competencies, including recognizing, communicating, and managing care needs and end-of-life care. Through a mix of video, podcast resources, and case-based online discussions, participants will explore symptom management, health trajectories, and best practices while considering ethical and legislative factors specific to their region.
  • Learning Objectives:
    By the end of the course, participants will be able to:
    • Differentiate chronic vs. acute conditions needing palliative care.
    • Describe health trajectories and typical modes of dying.
    • Use a communication framework for symptom discussions.
    • Identify palliative interventions for breathlessness and pain.
    • Recognize signs of active dying.
    • Discuss cultural perspectives on end-of-life care.
    • List pharmacological and non-pharmacological symptom management strategies.
  • Link: Palliative Care in the Emergency Department eCourse 

• GEDC Geriatric EM Online Resources
  • Course Description:
    This free e-learning series is designed primarily for clinicians working in emergency departments who want to provide optimal care to their older patients.
  • Learning Objectives:
    By the end of the course, participants will be able to:
    • Identify atypical disease presentations in older adult ED patients.
    • Describe approaches to cognitive impairment in older adults in the ED.
    • Employ comprehensive measures in fall management.
    • Describe end of life symptom management for older adults in the ED.
    • Discuss the impact of frailty on older adults presenting to the ED.
    • Describe functional assessment of older adult ED patients.
    • List specific challenges in trauma care for older adults.
    • Describe principles of medication management for older adults.
  • Link: Geri-EM Online

ED Palliative Program Highlight

Hospital: North Shore University Hospital (80,000 annual visits, level 1 Trauma Center, 800+ beds) & Long Island Jewish Medical Center (>100,000 annual visits, 800+ beds, affiliated with Cohens Children Hospital, level 1 Trauma Center for pediatrics)

Residency: Hofstra Northwell Emergency Medicine Residency Program

Fellowship: Hospice & Palliative Medicine at Northwell Health (covers multiple hospitals, palliative care units and hospice facilities within Northwell Health, a 23 hospital health system)

Model: Having a dedicated palliative care physician in the ED facilitates prompt goals-of-care conversations, ensuring patient-centered decisions and optimizes resource allocation during the critical initial phase of care.

Lesson Learnt: Having this resource can also potentially reduce unnecessary hospital admissions, procedures, and readmissions, thereby lowering healthcare costs. It also equips ED clinicians with readily available palliative care expertise, while enhancing their ability to navigate complex care decisions and provide comprehensive care. 

Thank you Dr. Payal Sud for sharing!

Research Articles of the Month

Palliative Care Boot Camp Offers Skill Building for Emergency Medicine Residents

Cooper J, Fredette J. Palliative Care Boot Camp Offers Skill Building for Emergency Medicine Residents. West J Emerg Med. 2024 Nov;25(6):913-916. doi: 10.5811/westjem.18381. PMID: 39625763; PMCID: PMC11610741.

What the Author Did
The author designed a four-week "Palliative Care Bootcamp" to teach emergency medicine (EM) residents primary palliative care skills. This included recognizing patients needing palliative care, managing symptoms, conducting goals-of-care conversations, and collaborating with interdisciplinary teams. The curriculum used lectures, case discussions, and simulations to improve residents' knowledge and confidence.

Why It Matters
EM physicians often encounter critically ill patients but lack formal training in palliative care. This bootcamp bridges that gap, equipping residents to provide better patient-centered care in the emergency department. The model shows promise for wider adoption in residency programs to enhance palliative care integration in acute care settings.

Announcements

We’re excited to announce the new section leadership team!

Section Chair: Justin K Brooten, MD
Section Chair-Elect: Alex Zirulnik, MD, MPH
Secretary: Alice Chang, DO
Co-Secretary: Allison Tadros, MD
Councilor: Brian Gacioch, MD
Alternate Councilor:  Daniel Boron-Brenner, DO
Board Liaison: Rami Khouri, MD, FACEP
Section Liaison: JoAnna Putman

We are also looking to have someone from our section join the ACEP Education committee.  Applications are due May 15, 2025, and please feel free to reach out to Justin Brooten by email or through ACEP EngagED if you are interested.

ACEP Council 2024

We had a very productive ACEP council prior to the start of ACEP 2024.  Justin Brooten served as our section Councilor for this meeting session.  Council is an opportunity for sections to present resolutions addressing key issues in Emergency Medicine.  Two resolutions which were passed directly related to the care of patients with end of life and palliative care concerns. 

Resolution 50(24) related to concerns regarding patients who present to the ED with terminal conditions and Resolution 34(24) was related to reimbursement pathways for care provided outside of the hospital by EMS systems, such as hospice patients who may be treated by EM in place instead of transported, since care reimbursement is typically tied to hospital transportation.  This highlights the ongoing need for representation by palliative care informed emergency physicians at ACEP council and we are glad to have Brian Gacioch, MD and Daniel Boron-Brenner, DO serving in that capacity in the future.

Leaders in Transition

Our Section Chair: Justin Brooten, is pleased to announce that he will be transitioning to an interim role as the Hospice and Palliative Medicine Fellowship Program Director at the Wake Forest School of Medicine, in Winston Salem, NC starting April 1.

References

• Fast Fact #246. Sangeeta Lamba MD, Tammie E Quest MD, David E Weissman MD. Published March 2, 2019. https://www.mypcnow.org/fast-fact/emergency-department-management-of-hospice-patients/. Retrieved 12/15/24
• Palliative Care in the Emergency Department e-Course. https://eusem.org/education/courses-traineeships/palliative-care-in-the-emergency-department-ecourse
• Cooper J, Fredette J. Palliative Care Boot Camp Offers Skill Building for Emergency Medicine Residents. West J Emerg Med. 2024 Nov;25(6):913-916. doi: 10.5811/westjem.18381. PMID: 39625763; PMCID: PMC11610741.