Am I Doing the Right Thing? Provider Perspectives on Improving Palliative Care in the Emergency Department

• Published in: Annals of emergency medicine Vol. 54; no. 1; pp. 86 - 93.e1
• Main Authors: Smith, Alexander K., Fisher, Jonathan, Schonberg, Mara A., Pallin, Daniel J., Block, Susan D., Forrow, Lachlan, Phillips, Russell S., McCarthy, Ellen P.
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.07.2009; Elsevier
• Subjects: Adult; Advance Directives; Aged; Allied Health Personnel; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Attitude of Health Personnel; Biological and medical sciences; Clinical death. Palliative care. Organ gift and preservation; Emergency; Emergency Medicine - methods; Emergency Medicine - standards; Emergency Service, Hospital - standards; Female; Focus Groups; Humans; Intensive care medicine; Internship and Residency; Interprofessional Relations; Male; Medical sciences; Medical Staff, Hospital; Middle Aged; Nursing Staff, Hospital; Palliative Care; Physicians, Family; Practice Patterns, Physicians; Quality Assurance, Health Care; Resuscitation Orders; Social Work; Young Adult; Palliative care; Intensive care; Emergency department; Resuscitation
• ISSN: 0196-0644; 1097-6760; 1097-6760
• DOI: 10.1016/j.annemergmed.2008.08.022

Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods. We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus. Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patient's family and written advance directives); and (6) training in pain management is inadequate. Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.