Palliative Care in the Emergency Department: Insights from a Virtual Panel

People living with serious illness are common visitors to their local emergency departments (EDs), driven by symptom exacerbation, disease progression, treatment side effects, and even caregiver fatigue. While many of these patients can benefit from specialty palliative care services, reliable access in the ED is still a rarity.

To learn more about the opportunity to deliver palliative care in the ED, we spoke with five palliative care leaders across the country who successfully provide palliative care services in the ED. This blog summarizes their experiences and advice, so other program leaders can best leverage this high-impact opportunity.

We thank our colleagues for sharing their experiences in this piece:

• Ryan Baldeo, MPAS, MSPC, PA-C, FAAHPM, Palliative Care Physician Assistant, Mayo Clinic Arizona (now with Stanford Health Care)
• Sara Elliott, MSN, RN, Palliative Care Program Coordinator, JPS Health Network
• Tammie Quest, MD, Palliative Care Center Director, Emory University
• Megan Prescott, LCSW, APHSW-C, Clinical Social Worker, University of Colorado Hospital, Aurora
• Leah McDonald, MD, ED Site Supervisor, Hope Health (and Assistant Professor of Medicine, Brown School of Medicine)

Published literature on palliative care delivery in the ED shows significant positive outcomes, including reductions in symptom burden; shortened length of stay for those admitted to the hospital; increases in hospice utilization and length of stay; improvements in patient/family satisfaction; and decreases in unnecessary health service utilization. One study demonstrated a reduction in hospital length of stay as high as 3.5 days, along with a median cost avoidance of more than $9,000 per patient.

These positive outcomes were echoed in our conversations with palliative care leaders.

While Ryan Baldeo, MPAS, MSPC, PA-C, FAAHPM, was at Mayo Clinic Arizona (he is now with Stanford Health Care), his work in the ED caught the attention of hospital leadership. They appreciated the chance to give person-centered care to patients earlier, and the resultant reductions in spending, ICU length of stay, and readmissions. Palliative care in the ED also resulted in fewer high-risk surgeries, which improved the hospital’s mortality statistics.

In a public hospital system in Texas, Sara Elliott, MSN, RN, has added value to her organization (JPS Health Network) by focusing on and improving performance in key quality programs, where palliative care encounters are exclusions in the calculations (especially the CMS sepsis measure and the Potentially Preventable Events programs, where removing these patients from both the numerator and denominator appropriately risk-adjusts the measure and typically improves performance. Her palliative care team’s collaboration with the ED also resulted in a 60% length-of-stay reduction and a 48% reduction in in-house mortality compared to palliative care consultations placed outside the ED.

Beyond this business case, Mr. Baldeo (Mayo Clinic Arizona) also highlights the benefits to ED clinicians. There was a morale benefit to having palliative care support in the ED, helping the team feel assured that they were doing the right thing for patients and allowing them to hear about goal-aligned care delivery after ED discharge.

While the benefits can be substantial, palliative care can play different roles in the ED and can—and should be—nuanced. We heard from Tammie Quest of Emory University about two distinct patient populations in the ED: emergent and urgent, and how palliative care must play a different role for each. Per Dr. Quest, “When patient needs are emergent (e.g., prognostically minutes to a few short hours), there should be a focus on helping patients and families with immediate care plan changes and critical, in-the-moment decision-making; in fact, ‘primary’ palliative care by the ED team may have the greatest impact in these situations.”

For the urgent population (e.g., prognostically days to weeks), Dr. Quest urges that the ED visit should be the start (the "trigger") to a more longitudinal palliative care intervention, rather than the whole of the intervention. This trigger approach aligns with the experience of the other leaders interviewed, and with what’s in the published literature. For example, Ms. Elliott (JPS Health Network) points out that only about 10-15% of their ED consult requests come from the ED team, with the rest coming from the hospitalist or critical care team assigned to that patient. Interviewees cite enormous value in having palliative care specialists coordinate communication on what should happen next.

Megan Prescott, LCSW, APHSW-C, who works at the University of Colorado Hospital, Aurora, also describes much of her role in the ED as helping the next team better manage the care trajectory. This may mean empowering the attending or ambulatory provider with more information, sharing patient priorities so that care managers can better triage, or providing the palliative care team with a significant head start (on average, four days earlier than palliative care would otherwise have engaged the patient).

All interviewees stressed the importance of never disrupting the ED workflow. “Do not disrupt any important ED metrics like throughput and length of stay" urges Mr. Baldeo (Mayo Clinic Arizona), while Ms. Prescott (University of Colorado, Aurora) notes, “we want emergency care to take priority, and find that there is usually ample time to weave our discussions around the flow of evaluation, diagnostics and other specialty consultations without creating delays.” Multiple panelists also shifted their day to accommodate early evenings and reach more patients in need.

Leah McDonald, MD, with Hope Health (providing care at Miriam Hospital, Brown Health), stresses that any palliative care professional in the ED must be agile and not only comfortable but passionate about crisis work. “I get involved before we know the outcome of the plan,” she says, “There’s tremendous value to starting conversations before there’s knowledge of what’s coming. And getting patients’ goals clearer helps with what’s next.” All leaders stressed the essential ability to work with much less information and clarity than in other settings.

Dr. McDonald also stresses how essential it is to have a trusted system of referrals for those next steps. That includes the inpatient palliative care team, any community-based partners (including hospices), and champions on other care teams.

Lastly, and importantly, these leaders followed the proven approach to building collaborative relationships: they asked their ED colleagues what would be most helpful and started there. For example, Dr. Quest (Emory University) noted that managing opioids for dyspnea and analgesia is often an area where palliative care can be especially helpful, while Ms. Elliott (JPS Health Network) found a strong appetite for primary palliative care education among her ED colleagues.

Despite the commonalities across these ED palliative care interventions, there is significant variability in how ED palliative care interventions are implemented. Among the interviewees, there was no consensus on the primary goal of the palliative care specialist in the ED, with some emphasizing symptom management and others focusing on goals of care conversations. As a result, each program deployed different disciplines and numbers of staff. Noting the hierarchical culture and substantial medical needs in the ED, some rely only on a physician or physician associate, while one deploys a full IDT; Ms. Prescott (University of Colorado, Aurora) makes a strong case for a highly-skilled palliative care social worker because of the intense emotional needs involved in navigating next steps. Each interviewee made a viable argument for why and how their configuration works well in the milieu of the ED and given the substantial palliative care needs of the population, it’s clear that all five models make a valuable contribution to care and outcomes.

Dr. Quest notes that evidence supports that the impact on both quality of life and quality of care delivery is strongest when palliative care is delivered early. Despite that, palliative care in the ED remains an innovation and not a standard of care. The field remains unsure of what palliative care in the ED looks like, how often it’s needed, and who delivers it, particularly given the diverse ED patient population. To start the movement into the ED, the program leaders on this virtual panel—as well as others working in rural EDs—have successfully proven feasibility, acceptability, and financial viability, even within this diversity.

With heightened uncertainty in the U.S. health care system, now is the time to shift more palliative care into the ED. State champions pursuing Medicaid benefits/requirements for palliative care may find incentives for initial engagement in the ED a worthwhile strategy, while inpatient palliative care leaders can look to expand their services to the ED to demonstrate a measurable impact from their programs.

• Emergency Department: Integrating Palliative Care, a CAPC toolkit developed by the Advisory Board of IPAL-EM: Improving Palliative Care in Emergency Medicine.
• The Geriatric Emergency Department Collaborative (GEDC), a worldwide collaborative of health care professionals, systems, and organizations dedicated to improving the quality of care for older people in EDs to reduce harm and improve health care outcomes.
• Billing and Coding for Critical Care Codes in the ICU and ED, a CAPC resource that helps determine patient eligibility, which providers can bill, understand time-based billing, and what documentation is required.