Chapter 299: Palliative Care

INTRODUCTION

The goal of palliative care is to relieve the suffering of patients with serious illness. Regardless of the patient's prognosis, relief of suffering should be a primary goal for both emergency medicine and palliative care.¹ Palliative care is defined by specialty advocates as the physical, spiritual, and psychosocial care given by multiple disciplines to patients and their families who are living with life-threatening illness.² Although these principles are applicable to all stages of a patient's illness, a palliative care consultation from the ED is generally considered in the context of previously predicted end-of-life care. Hospice care, a branch of palliative care, is a comprehensive program of palliative treatment that is appropriate when patients with chronic, progressive, and eventually fatal illness are determined to have a life expectancy of 6 months or less. Palliative care is patient centered rather than disease centered. It strives to ensure that the patient or his or her (formal or informal) representatives have chosen realistic goals of care after the patient's diagnosis, prognosis, and therapeutic options have been considered. This discussion and decision making should take place during a meeting that includes the patient's healthcare team, surrogate decision maker(s), and those loved ones who are privileged to receive confidential information.

Palliative care is guided by the axiom that distressing symptoms should be treated. It thus provides expert assessment and treatment of symptoms, including pain, dyspnea, and vomiting. Pain is the most common reason for seeking care in the ED, accounting for 58% to 78% of visits in the United States.^3,4,5 Unfortunately, only 60% of patients reporting pain receive pain medications, and 74% of patients who present in pain are discharged in moderate to severe pain.⁶ Dyspnea is the sixth most common chief complaint and vomiting the ninth most common chief complaint of patients presenting to the ED⁷; statistics are not available to document the success or failure of the emergency physician's attention to alleviating these symptoms.

Palliative care also trains healthcare professionals to compassionately communicate diagnosis, prognosis, and treatment alternatives and guide the formulation of a therapeutic plan. Palliative care clinicians work to coordinate caregivers and interventions for the patient and family, to make care more effective, and to lessen the stress and obstacles for achieving satisfactory outcomes. Standards for compassionate care spelled out by the Institute of Medicine⁸ and numerous professional societies require that distressing symptoms be alleviated concurrently with all treatments directed toward the pathology of the medical disorder. The patient or surrogate must play a key role in decisions regarding care.

The subspecialty of hospice and palliative medicine was co-sponsored by the American Board of Emergency Medicine, recognized by the American Council of Graduate Medical Education, and officially approved by the American Board of Medical Specialties in 2006. In the spring of 2007, the American Board of Emergency Medicine approved the seating of duly ...