Providing palliative care in the ER

For some people living with a serious chronic illness, visiting the emergency room (ER) may become a familiar routine as the disease progresses and symptoms worsen. Sometimes, patients are treated and leave the ER, only to return for the same symptoms, or are admitted to the hospital’s intensive care unit (ICU) if the disease has progressed to a critical stage.

The Sharp Grossmont Hospital Advanced Illness Management (AIM) team is working toward addressing the needs of patients with serious chronic illness who frequent the ER while reducing readmissions. A coordinated group of nurse practitioners and physicians, specializing in palliative care and advance care planning, work alongside emergency medicine clinicians to provide the right care at the right time for such patients.

“We saw a need to have palliative care experts in the ER to work with patients living with chronic or life-threatening conditions,” says Debra Bennett, a nurse practitioner with the AIM program. “The ER is a dynamic place, and the doctors and nurses may not always have the extra time to sit down with a patient to discuss their health care goals or their quality of life at home,” says Bennett. “Our team fills that gap.”

Candid conversations
Having the patient and AIM team connect at an early stage, Bennett says, such as during the ER encounter, is valuable for increasing the patient’s chance for a better quality of life as their disease progresses. “The earlier we get palliative care involved, the better the patient’s outcome will be.”

In the ER, the AIM team talks with the patient and their family about the progression of their illness and how they are doing at home. They can estimate the patient’s prognosis and offer suggestions on a path of care that meets the patient’s wishes and can provide a better quality of life during the patient’s lifespan.

Sometimes, the goal is to ensure that the patient does not end up being admitted to the ICU or undergo invasive treatment interventions that may not improve their outcome or are not consistent with the patient’s wishes.

“When someone with a chronic illness comes to the ER, it is because they have an acute situation that needs care immediately,” says Bennett. “If prognosis beyond the acute illness seems poor, our team steps in and speaks with the patient and their loved ones about palliative care plans for the future. This may include decisions about resuscitation and hospice care.”

For instance, a patient living with heart failure may come to the ER for worsening symptoms. “We will talk with them about the status of their illness and ask if more treatment is available and likely to be helpful,” she says. “We’ll talk about what life at home is like, in terms of how they get around, bathe or dress; what they enjoy doing and gives their life meaning; and how their illness relates to those things.”

The choice of palliative care
Sometimes, the patient and loved ones decide to shift from curative treatment to palliative care to keep the patient comfortable and improve their quality of life. The AIM team then works with them to coordinate the care.

“People are generally appreciative of the information we provide, and many are not aware that they are coming to the end of their life,” says Bennett. “Some people react with surprise, some are relieved — it’s almost like holding a mirror up to them. But more often than not, they are grateful for having the conversation.”

Bennett recalls a gentleman with end-stage lung disease. “He had been in the ER multiple times as his illness progressed,” she says. “He was frightened during his episodes of breathlessness, but he didn’t want to keep coming back to the hospital.”

Bennett’s team met with him and discussed his goals and how his symptoms could be better managed at home. He left the ER with hospice care, and she reports he was able to die peacefully at home, an experience made better for him and for his partner.

Finding her work both rewarding and challenging, Bennett admits she has to be brave every day. “I am going into what can be uncomfortable situations and I don’t know how people will respond,” she says. “But generally, by having the courage to have these difficult conversations, I feel that I am making a positive difference in their lives.”

Learn more about palliative care services at Sharp Grossmont Hospital.