This is a new US initiative called IPAL-EM which stands for Improving Palliative Care in Emergency Medicine. The program aims to increase the use of palliative medicine in seriously ill patients brought to the ER. The idea here is that every seriously ill hospitalized patient should have access to palliative care, and the emergency department is no exception. The program will share with the ER best practices that are already in place in other parts of the hospital.
The authors believe it's necessary to bring palliative care to the ER for several reasons. First, while a large percentage of patients say they'e prefer to die at home, many patients who are terminally ill show up in the ER. They may do so when death is imminent, or when they develop an acute illness like pneumonia, or for symptom control, typically pain control. ERs need to have the knowledge and skill to help these patients. The second reason is that you don't have to be dying to benefit from palliative care. These days, patients with cancer receive palliative care much earlier in the diagnosis. ER health care providers need to be skilled to manage pain at all stages of cancer. As well, there's a whole host of other chronic diseases where palliative care plays a role. Patients with chronic heart failure have persistent shortness of breath that we can sometimes manage palliatively.
To me, it's not hard to see why more ER physicians haven't embraced this new way of thinking. ER physicians are experts in knowing how to treat acutely ill patients brought to the hospital at death's door. Residency programs have traditionally focused almost exclusively on that end of things - saving lives or keeping people alive until you can get them to the intensive care unit. I think that reinforces a message that death represents personal defeat or failure on the part of the ER. ER doctors are really good at recognizing patients who are dying. But they aren't as good at recognizing patients who might benefit from palliative care. I also think there's a deep bias in ER medicine against managing symptoms. We tend to think of it as the poor cousin to curing disease.
Want to make ER doctors and nurses uncomfortable? Put a dying patient in the ER being cared for by a team of doctors and nurses making no effort to try and save them -- without mentioning that the patient is palliative. ER staff will begin to get fidgety and anxious and start asking "why is no one doing anything to save them?' If I'm on duty, I might be asked to check up on the patient to make certain everything is alright.
I see that all the time. I also see it with patients who aren't at imminent risk of dying yet who might benefit from palliative care. Patients with chronic heart failure come to mind. The typical ER approach to heart failure is to use drugs to reduce the fluid around the lungs and to provide advanced airway techniques to give the patient more oxygen. The idea that we don't do that but give the patient a tiny bit of morphine to ease their breathing might be good palliative care but would be regarded by some of my ER colleagues as malpractice.
And, there are other issues regarding the culture of medicine that go beyond the ER. When palliative patients require admission to hospital, it can sometimes be difficult getting an admitting doctor to take them on.
Do I see something like the US initiative happening in Canada? I sure hope so. A 2010 study published in the Canadian Medical Association Journal found that of nearly 92,000 patients in Ontario who died of cancer, close to 77,000 of them came to the ER at least once during the last six months of life. They had symptoms like abdominal pain, lung cancer, shortness of breath, pneumonia, malaise and fatigue. Ideally, people who are dying should be able to avoid emergency department visits near the end of life. That means better palliative care at via home care. But if that doesn't happen, people like me better get used to delivering palliative care ourselves.
For your information, on November 17, the Parliamentary Committee on Palliative and Compassionate Care released a report that can be dowloaded here.