Several years ago while on duty in the emergency room at Emory University Medical Center in Atlanta, Dr. Knox Todd, now professor of emergency medicine at Beth Israel Medical Center in New York City, experienced a "Eureka!" moment that illustrated the need to import palliative care into the emergency department. A patient with advanced cancer went directly from her oncologist's office to the emergency department seeking treatment for her severe pain. She hadn't even mentioned the pain to the oncologist, Todd relates.

"The emergency department is a bottleneck and a staging area-a place of transition for many patients, whether from one health plan to another or one stage of life to another," he says. "It's a place of crisis and opportunity-where changes in treatment philosophy are easier to implement." But if therapies to manage troubling symptoms are not initiated in the emergency department for patients who get admitted to the hospital, there may be significant delays before their suffering is treated.

Todd and other national leaders in emergency medicine have been striving to incorporate palliative care techniques in their field. Their success is reflected in the recent decision by the American Board of Emergency Medicine to join with nine other boards of the American Board of Medical Specialties in cosponsoring hospice and palliative medicine as a recognized medical subspecialty. Other new initiatives to strengthen the interface between palliative care and emergency medicine include Todd's Pain and Emergency Medicine Institute at Beth Israel, funded by the Mayday Fund and the Samuels Foundation, and the new Center to Advance Palliative-Care Excellence at Wayne State University in Detroit, directed by Dr. Robert Zalenski, endowed professor of emergency medicine.

These advocates say that emergency physicians are hungry for knowledge of palliative care and would welcome overtures from palliative care programs within their institutions. The opportunity for building collaborative relationships between the two services will be addressed in a CAPC audio conference, "Moving PC into the ED: Ensuring the Right Care for Seriously Ill Patients-Right from the Beginning," on January 11, 2007.

Audio conference presenters, representing palliative care programs that have achieved collaborative relationships with their institutions' emergency departments, are Sharol Herr, RN, MA, and Philip Santa-Emma, MD, from the Palliative Care Services at Mount Carmel Health System in Columbus, Ohio, and J. Brian Cassel, PhD, senior financial analyst at Virginia Commonwealth University in Richmond, VA. (For information or to register, go to www.capc.org/support-from-capc/audio- conf/01-11-07-audio or call Margaret Schutz at 212-201-2671.)

Trends such as rising health care costs, overcrowded emergency departments, and data showing that patients with severe or chronic illnesses are likely to enter the hospital through the emergency room all underscore the opportunities for palliative care to build constructive relationships. However, palliative care professionals should keep a few key points in mind, suggests Dr. Tammie Quest, an emergency physician at Emory and medical director at Grady Hospice, also in Atlanta. "The focus and goal of emergency medicine is disposition," she says. "We need prompt and eager response. If we can even just get someone on the telephone to discuss the case with us, it helps with disposition."

As with any successful marketing effort, palliative care professionals need to learn and understand the processes and demands of the emergency department to determine ways to provide meaningful help. For example, they could offer palliative care training, tools and techniques that the emergency department can use immediately. Twenty-four-hour availability to the emergency department, while ideal, might not be necessary, Quest adds, so long as palliative care can demonstrate that it is reliably accessible and helpful within a predictable time frame.

Emergency physicians also want reassurance that they are doing the right thing, for example, when they order pain medications as palliative care recommends. "Most of all, you need to give them respect for the work they do and their commitment to patients under difficult and stressful circumstances," Quest says. There are a few magic words likely to make any emergency physician open and receptive to dialogue with palliative care: We want to help figure out how to identify and then move patients with palliative care needs out of your emergency department.

The palliative care program at Virginia Commonwealth University's Massey Cancer Center has made significant inroads with its emergency department, Cassel says. He reports that nearly half of all patients in the palliative care unit at Massey are directly admitted, either from the emergency department or physician referral.

Collaborating with the emergency department is a way to get earlier referrals and to have a direct effect on treatment planning and goal setting at the front door-a better approach than trying to redefine care goals days or weeks later in the hospital, Cassel says. Internal research at Massey indicates that significantly greater financial impact on the hospital's bottom line results from directly admitted patients, and that the palliative care team often is able to intervene in treatment decision making in the emergency department during the first minutes or hours after a patient turns up.

Other palliative care programs that want to achieve similar contributions to their hospitals' bottom lines need to be responsive to the emergency department's needs, such as by offering training, phone consultations, in-person consultations, family meetings in the emergency department or direct admissions where there is a palliative care unit able to accommodate such patients.

"The hospice and palliative medicine community hasn't really tapped into us the way they might, but emergency physicians think palliative medicine is a no-brainer," says Quest, who is participating in a new project with Dr. Linda Emanuel at Northwestern University in Chicago to develop an EPEC curriculum for emergency medicine. "My goal is to bring emergency physicians along to the point where we have established a floor of palliative medicine skills and competencies. But then to have hospital-based palliative care available to respond to the difficult cases would be ideal. The iron is hot for doing this right now."

The NPCRC, located at Mount Sinai School of Medicine, under the direction of R. Sean Morrison, MD, FACP, has been awarded a $5 million grant from the National Cancer Institute (NCI) of the National Institute of Health (NIH). According to Morrison, "The study will evaluate the impact of hospital palliative care on the quality of care for cancer patients and will create the evidence base necessary to determine which components of palliative care programs are key to their effectiveness."

The new multi-million dollar, multi-site study will assess the structure, processes, and clinical outcomes of care among hospitalized persons with advanced cancer that receive palliative care consultation team services, as compared to similar patients receiving usual hospital care. The study will look at palliative care consultation at five hospitals with well-established palliative care consultation teams, utilizing existing National Comprehensive Cancer Network-American Society of Clinical Oncology practice guidelines and protocols for pain and symptom management, patient-care team communication, and transition management.

The five performance sites are:

• Mount Sinai School of Medicine, New York, NY
• Virginia Commonwealth University, Richmond, VA
• Medical College of Wisconsin, Milwaukee, WI
• Mount Carmel Health Systems, Columbus, OH
• University of Pittsburgh, Pittsburgh, PA

In the October 16, 2006 issue of Newsweek, palliative care was presented as one of 10 solutions to fixing America's hospital crisis. The article, "Fixing America's Hospitals," highlights 10 U.S. hospitals that are ". . . using innovation, hard work and imagination to improve care, reduce errors and save money." Dr. Diane Meier, CAPC director, was featured along with her Mount Sinai team, as was Dr. Philip Santa-Emma, leader of the Palliative Care Leadership Center at Mount Carmel.

To view this segment of the article, click here.

Hospitals continue to implement palliative care programs at a rapid pace, according to a Center to Advance Palliative Care (CAPC) analysis of the latest data released in the 2006 American Hospital Association (AHA) Annual Survey of Hospitals. The CAPC analysis shows that 1,240 hospitals nationwide provide palliative care programs today. This is compared to 632 programs in 2000-a five-year increase of 96%.

"Ten years ago there were almost no hospital palliative care programs in the U.S. This continuous growth trend is very good news because if we are going to meet the needs of our aging population, every hospital must have a program," said Dr. Diane Meier, Director of the Center to Advance Palliative Care.

Of the 4,103 hospitals appropriate for palliative care programs (psychiatric and rehab hospitals are excluded):

• 50% with over 75 beds have a program
• 70% with over 250 beds have a program
• 57% of hospitals with a cancer program approved by the American College of Surgeons (ACS) have a program
• 75% of Council of Teaching Hospitals (COTH) members have a program
• 46% of hospitals in cities with a population of 1-2.5 million have a program

The Medical College of Wisconsin's (MCW) End of Life/Palliative Education Resource Center (EPERC) is currently accepting proposals for its initiative to assist six U.S. medical schools in improving palliative care education for 3rd/4th year medical students. Six medical schools will be selected through a competitive application process. Each of the six funded schools will receive a $41,000 award to support curriculum development.

MCW received a two-year, $513,000 grant from the Robert Wood Johnson Foundation to support this effort. The project is being directed by Drs. David Weissman, Susan Block, Timothy Quill and Deborah Simpson. Project goals include:

• Develop a self-sustaining, required and elective palliative care didactic and experiential training opportunity for 3rd and 4th year medical students
• Establish a faculty development palliative care program for existing and new faculty

Newsweek Features Palliative Care

Kalb, C. Fixing America's hospitals. Newsweek; October 2006.

To access the full feature, click here.
To access the article on palliative care, click here.


Frailty in Older Adults and Palliative Care

Boockvar, KS., Meier, DE. Palliative care for frail older adults: There are things I can't do anymore that I wish I could. Journal of the American Medical Association; 296(18) November 2006.

To access the abstract, click here.
To access the full article, click here.

Mark your calendars for these upcoming audio conferences with PCLC faculty . . .

Moving PC into the ED: Ensuring the Right Care for Seriously Ill Patients - Right from the Beginning
Thursday, January 11, 2007
1:30 - 2:30 PM Eastern

Featured Speakers:
Sharol Herr, RN, MA
Palliative Nurse Clinician & Education Coordinator
Mount Carmel Health System

Philip Santa-Emma, MD
Medical Director, Palliative Care Services
Mount Carmel Health System

J. Brian Cassel, PhD
Senior Analyst
VCU Massey Cancer Center

Learn More and Register


Calculating Financial Outcomes for Hospital
Palliative Care
Wednesday, March 14, 2007
1:30 - 2:30 PM Eastern

Featured Speakers:
Kathleen Kerr
Senior Analyst, University of California, San Francisco
Faculty, UCSF Palliative Care Leadership Center

Steven Pantilat, MD
Associate Professor
University of California, San Francisco

Learn More and Register