Does palliative care belong in the ER?
NEW YORK (Reuters Health) - Hospital administrators tend to agree that it's a good idea to have emergency departments offer palliative care, which is focused on providing comfort and respecting patients' wishes rather than centering only on prolonging the patient's life, according to a new study.
But one of the biggest barriers to getting palliative care in the ER is the physicians.
"There's a stigma that palliative care is the same as end of life care, the same as hospice," said Dr. Corita Grudzen, the lead author of the study and an assistant professor in the department of emergency medicine at Mount Sinai Medical School.
Physicians who are trained in rescuing lives might view palliative care as giving up.
Grudzen said palliative care can be given along with life-saving treatment.
Palliative care has two components: one is seeking to follow patients' desires for treatment, such as whether they want to be resuscitated; the other is managing pain, shortness of breath and other aspects of a person's comfort.
Only in recent years have some medical organizations and doctors pushed for palliative care to be available in emergency departments.
"The questions some people have is, 'should we really be discussing things like whether people want to be resuscitated or intubated during a crisis moment, if it hasn't been addressed before,'" Grudzen told Reuters Health.
"I think we have a moral obligation and legal obligation to do what people want and to address it before we do these aggressive things," she added.
To gauge how hospital leaders feel about palliative care in the ER, Grudzen and her colleagues interviewed 14 emergency department heads, hospital administrators and palliative care administrators at three hospitals.
Overall, they found administrators to be supportive of offering palliative care in the ER.
For instance, one administrator told the researchers, "'the most rewarding letters are ones we receive from families of patients who have passed away that had access to the palliative care program.'"
But the biggest barrier to palliative care seems to be the doctors, Grudzen said.
For one, the administrators felt that emergency physicians don't have the time to discuss how much intervention patients want.
One said, "'emergency physicians have a limited ability to focus on anything other than the 300 patients they're going to see today.'"
Also, emergency physicians don't think of palliative care as part of saving lives.
As one administrator put it, "'palliative care has a bad rap because people think of it as death care.'"
Dr. Alexander Smith, a geriatrics and palliative care researcher at the University of California, San Francisco, said palliative care can be given right along with life-prolonging treatments.
He said that palliative care needs to rebrand itself among emergency physicians to become accepted in the ER.
"If most emergency physicians don't understand what palliative care is, and does and has to offer, then it's hard to think about where to go from there in integrating it into the field," he told Reuters Health.
Grudzen found in the interviews that another perceived barrier to implementing palliative care is concern over litigation - that doctors might get sued because they didn't do enough to save a person's life, even if they respected that patient's wishes.
"'Just do the most so we don't get sued,'" said one hospital leader.
"That seems wrong," said Smith. "That is not the correct answer for many patients because it doesn't fit with their goals."
Administrators told Grudzen that educating ER doctors about palliative care would likely make them more open to it, and that creating specific guidelines for assessing ER patients' palliative needs would make their access to palliative care "less random."
Grudzen said she doesn't think all ERs are ready for palliative care, and even if they were, there aren't enough specialists to staff every one.
But interest is growing.
The American Board of Emergency Medicine now offers a subspecialty in palliative medicine.
"Just building those skills among emergency physicians is really kind of key," she said.
SOURCE: bit.ly/PUcql6 Annals of Emergency Medicine, online July 7, 2012.
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