A Case for Education in Palliative and End‐of‐life Care in Emergency Medicine

In this issue of Academic Emergency Medicine, a resident author vividly describes the challenging case of a conscious patient who presents with an acute, catastrophic, nonsurvivable illness.1 This portfolio submission recounts an unenviable task that, while uncommon, is a shared experience of most emergency physicians (EPs): providing a prognosis of impending death to an unsuspecting patient. Communicating such horrific information is a high-stakes event—physicians never have a second chance to deliver that bad news differently or better. I commend the author for doing an excellent job when faced with this duty for this first time. Clearly the resident exhibited empathy and professional competence that will be remembered by the patient’s family members for years to come. Although the resident performed well in this case, the reflection highlights the need to improve the training of EPs in the domains of palliative and end-of-life care. The author considers, “how many times I had done scripted bad news notification . . . [but] this situation was so drastically different . . . death had not occurred but was certain and near.” The implication is that this clinical case was uncharted territory for which the resident had not been adequately prepared. What if the case did not result in such a rewarding, positive patient interaction? What if the resident had performed poorly? How would such an outcome affect the remainder of the resident’s training and future care in similar situations? Although a negative clinical experience can at times result in provider growth and maturation, a high-stakes error can be paralyzing for some residents. Training in palliative medicine and end-of-life care augments the natural humanism of a provider with deliberate, formal education in topics germane to the care of patients with life-threatening or severe advanced illness. Palliative medicine seeks to alleviate suffering and promote quality of life. Principles of palliative medicine can be applied in the emergency department (ED) to address the various forms of physical, psychological, social, and spiritual suffering associated with terminal disease. Primary skills of palliative care for emergency providers include treatment of pain and other symptoms common at the end of life, delivery of bad news, and assistance to patients and family members trying to cope with urgent and difficult treatment decisions.2 Four core cognitive domains of palliative medicine are evident in the case recounted in the resident portfolio: 1) death trajectories, 2) prognostication, 3) breaking bad news, and 4) goals of care. Patients at the end of life present to the ED along one of four global death trajectories that describe progressive inability to perform activities of daily living over time. Recognizing that a terminally ill patient exhibits features of a defined death trajectory helps the emergency provider to offer an evidence-based prognosis that better informs treatment options. The four common death trajectories are terminal illness (prolonged illness with sharp decline in function), organ failure (sharp decline in function with intermittent severe symptomatic crises), frailty (slow decline in function, with death due to a complication of progressive disability), and sudden death (trajectory reserved for patients without chronic illness). Only 15% of patients die from sudden illness.3 While emergency providers are presumed experts in issues of sudden death, this uncommon presentation allows for relatively infrequent experiential learning and practice opportunities for trainees. A prognosis is the most likely outcome of a disease. The formulation of a prognosis helps to guide patients and caregivers about necessary immediate actions and decisions. Prognostication is based on pattern recognition of identifiable clinical markers that can be compared to objective, well-researched prognostic tools that yield a quantitative prediction of disease outcome. Common barriers to prognostication in the ED include limited time for assessment, lack of necessary information from the patient or caregivers, and a lack of familiarity with prognostic tools.2 In the case described in the resident portfolio, both the radiologist and the surgeon offer immediate and direct prognoses based on minimal patient information. The resident author initially seems surprised by the reflexive nature of the consultants, asking, “What does the radiologist know? . . . He cannot see the patient.” This lack of familiarity with prognostication is a reflection on the current scope of training in our specialty. While EPs need not be facile with every available prognostic tool, the formulation of a broad prognosis can improve patient care by guiding decision-making, treatment recommendations, and management strategies.2 Communicating difficult news in a concise and compassionate manner is an essential and valued skill for emergency providers. When performed well, communication of difficult news can lead to a strengthened patient–provider relationship that nurtures realistic goals, autonomous decision-making, and a potential for patients and family members to better plan and cope.2 Good communication skills are learned and practiced. Trainees should be taught common protocols for delivering bad news, and they must be given the opportunity to practice these skills through role playing, through an objective structured clinical examination, or with a high-fidelity patient simulator.4 Buckman’s SPIKES protocol5 for communicating difficult news and Hobgood’s GRIEV_ING protocol6 for death notification both offer structured methods of teaching core communication skills necessary in palliative emergency medicine (EM; see Table 1). Patients make choices for medical care based on available prognoses dictated by their stage of illness, the risks and benefits of offered therapies, religious beliefs, and their own personal priorities. Eliciting and communicating goals of care help to answer the questions, “What are we doing?” and “Why are we doing this?” Poorly defined goals can lead to unwanted or inappropriate treatments, as well as prolonged and undue suffering.2 Emergency providers can help patients understand the goals and limitations of curative and palliative therapies. Symptom management and relief of suffering are the focus of palliative therapies, which can coexist in a care plan alongside attempts for cure. Palliative care is active total care—providers can always offer some therapy to a dying patient, even if the goal of such therapy is to minimize suffering in the hopes of a “good death.” Education in palliative care offers deliberate language and approaches that help physicians deliver bad news, offer prognoses, and elicit goals of care. In 2006, the National Cancer Institute funded an expert advisory panel of EPs, palliative medicine specialists, hospice directors, and nurses to create a curriculum in primary palliative care for emergency providers.7 The Education in Palliative and End of Life Care in Emergency Medicine (EPEC-EM) Project is a nonprofit, train-the-trainer course with a stated mission, “to educate all emergency healthcare professionals on the essential clinical competencies in emergency palliative care.”2 Core palliative care domains identified by the advisory panel as essential to the practice of EM are summarized in Table 2. The EPEC-EM curriculum was designed to elevate the practice of EM by amassing the best available evidence to guide the care of patients with advanced or terminal illness. The course recognizes the strengths and limitations of current EM residency training; as in the example offered in the resident portfolio, there are potential opportunities to refine residency curricula and improve the knowledge and skills of even our best trainees. As subspecialty certification in palliative medicine is now open to EPs through the new American Board of Hospice and Palliative Medicine,8 residency directors may find the EPEC-EM curriculum to be a useful resource for faculty and residents who are interested in accessing EM-specific palliative medicine training materials. Editors of the next revision of the Model of Clinical Practice in Emergency Medicine9 may consider the EPEC-EM curriculum as a potential source for evidence-based content in palliative and end of life care domains.