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EDs Lacking in Palliative Care, Report Says
Despite a slow decline and a realization that the end of life may be near, some terminally patients, accompanied by family, still seek care in the emergency room to manage symptoms or pain.
But emergency department staff lack necessary training to deal with palliative care, according to a report in the Annals of Emergency Medicine, which called it "a sadly neglected area of research, professional development and practice." The Annals is the scientific journal published by the American College of Emergency Physicians.
Interviews with patients and families as well as staff revealed a pattern in which these terminal patients felt abandoned or ignored or as one described "stuck in a corner and left there," while staff attended to patients with more urgent needs.
Rather, they're more focused on resuscitating patients who also may be dying, but whose decline is more catastrophic, traumatic, and sudden.
"Patients and their families receive a lot of attention and support in the emergency department when there is an unexpected acute medical illness or a sudden, often traumatic event that results in death," said lead study author Cara Bailey, MD, adult nursing lecturer at the College of Medical and Dental Sciences at the University of Birmingham in the UK.
"While the emergency department is not designed for end-of-life care, the reality is that many patients in this category go there for help, sometimes not realizing this is the end." Despite the presumption that people like to die at home, in the United Kingdom, at least, 66% of people in the UK die in hospitals, the researchers said, one-third of them in the first few hours after arrival to the ED.
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Comments are moderated. Please be patient.
Mark Rosenberg (12/12/2010 at 7:04 AM)
At St Josephs regional medical center in Paterson NJ we started a an emergency department based palliative medicine program. Since January 2010 we have touched the lives of more than 90 patient with terminal illness, organ failure and frailty. The program consist of myself and an RN coordinator. We anticipate helping manage more than 200 patients in 2011. If you want more information ... Feel free to contact me at rosenbem@sjhmc.org. Thank you Mark Rosenberg, DO, MBA, FACEP Chairman Emergency Department Geriatric Emergency Medicine Palliative Medicine
Mark Hauser MD (12/11/2010 at 2:41 PM)
It is an unfortunate truth that patients and families with lack of access to appropriate care have no choice other than coming to the emergency room. End-of-life care in the US is fragmented. Physicians, case managers and hospital discharge planners should be having end-of life discussions with patients and families in anticipation of expected symptoms and death but, as these discussions are difficult, emotionally charged, time consuming and uncompensated, they are often avoided. Even with good end-of-life planning, community resources like Hospice and palliative care beds are often in short supply leaving families little option other than the the ER while on waiting lists. Lack of prior designation of status as a palliative care situation with DNR, Health Directive, 5 wishes or the POLST form (the newest and best) leaves the emergency physician, who has no prior relationship with patient and family, in the difficult position of having an end-of-life discussion with those present or contacted by phone, often interrupted by the need to attend to emergencies elsewhere in the department. During this time, resuscitation, diagnosis and treatment can not be withheld. An intubated patient on pressors, with antibiotics in, blood products coming, returning from the CT scanner when the decision for comfort-care is made is terrible ordeal for patient and family as well as waste of resources. It is completely appropriate for a palliative care patient to come to the ER when their comfort-care needs can not be met in some other way. We have the pain and anxiety relieving drugs and a caring staff who can provide emotional support. We definitely need more education about end-of-life care. Using more respiratory and blood pressure depressing drugs when cardiopulmonary status is fragile is difficult for some emergency care providers. The goal of a comfortable death rather than prolonging life is hard for some to accept. Patients who have chosen palliative care have not "given up" and should never be neglected. A private room for patient and family in a busy ED may be difficult or impossible to arrange. Protocols for rapid admission to an in-patient palliative care bed are useful. If we had better end-of-life care in the United States, using the ER for palliative care needs would be rare. We lack the political will to address end-of-life care on a national level. Politics have blocked national policy development, health care worker and community education, compensation for end-of-life discussions, and adequate compensation for Hospice care (if yearly emergency mandates to postpone Medicare cuts are not passed many community's already limited Hospice programs would collapse). Direct admits to in-patient palliative care beds are problematic. We should all be advocates for a better end-of-life care system, and for better end-of-life care in the community including the ER and hospital when needed. Mark Hauser MD Emergency Physician Santa Barbara, CA
KAREN HARRISON RN (12/8/2010 at 9:35 AM)
As a recently retired ER nurse I feel the need to address this article. I beleive that it is up to each individual nurse to handle every given situation that is put in front of them. A patient that comes to the ER for pain control, or just because the family is scared and lost as to what to do for the dying family member, they look to us for compassion, understanding and knowledge. It is our job to make the patient comfortable and to keep the family informed as the process has begun. At my ER (Northeast Baptist, San Antonio) when we recieved a patient that we knew probably would not make it thru the night, we would call the house supervisor and get permission to keep the patient in the ER. (Our thoughts were that since the patient and family already had a relationship with the ER staff that we would try to keep their anxiety level down and keep them with who they already felt comfortable with.) We would keep the family informed of the process and we would keep them at the beside of the patient. At no time did we tell them how to feel or did we ever feel at a loss for words. I have lost family members and I could sympathize with them. There were tears from the staff and family alike. When the vitals showed the patient getting closed to passing on we would tell the family and be right beside them when it happened. All of this took great compassion and understanding from not only the nurse but of the administration as the nurses caring for a dying patient we needed to figure out how to give complete and competent care to all of our patients. I understand that not all ER's are capable of this due to short staffing or larger patient to nurse ratios but again I say that it is up to the individual nurse (with the backing of a great administration) to handle that situation and to look and treat that patient and family as they would treat their own. I hope that this story sheds light on the need for this very special type of nursing.