Practically speaking: emergency medicine and the palliative care movement.

Daily experience in the ED suggests that patients suffering from chronic life-limiting illnesses are all too often caught in a revolving door of emergency care that wastes resources and fails to properly address their stage of disease and goals of care. With regularity, these patients cycle from acute episode to acute episode – from the ED to a hospital bed and home again – without being offered palliative care services that could ease distressing symptoms, improve coordination of services and provide caregiver relief. Critical decisions made in the ED can determine the subsequent intensity and trajectory of medical treatments for life-limiting illnesses, which include appropriate levels of hospital care (including intensive care unit utilization). Thus, the ED is a crucial setting for identifying unmet palliative care needs and initiating end-of-life discussions with patients, families and primary care physicians to ensure appropriate care. Traditionally, specialty-level palliative care services receive consults and referrals long after hospital admission, and often in the last few days of a patient’s life. Emergency physicians in the USA and Australia have an important opportunity and responsibility to intervene in the debilitating downward spiral of repeated acute care episodes among frail ED patients. With an increased emphasis on ED-based palliative care, patients who can benefit from palliative care services will be identified more frequently and earlier in the course of their illness. The palliative care service at Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia, USA was an early innovator in this area, making a concerted effort to provide palliative care services to the ED. As a result of their efforts, the VCU ED began admitting significant and increasing numbers of patients directly to the palliative care unit rather than to general medical wards or intensive care units. In 2004, the Wall Street Journal highlighted the dramatic decreases in cost of care resulting from their avoidance of inappropriate intensive care utilization and reductions in excessive laboratory testing and imaging. By 2006, the number of academic emergency physicians in the USA with an active interest in palliative care became sufficient to justify our first developmental meeting. This workshop, entitled Establishing a Palliative Care Research and Training Agenda for Emergency Medicine, was held in San Francisco at the 2006 annual meeting of the Society for Academic Emergency Medicine. Dr J Brian Cassel, a member of the Palliative Care Leadership Center at VCU, attended and was an influential participant in this meeting. As noted in the article by Lukin et al. in this issue, the American Board of Emergency Medicine in 2006 supported the new subspecialty of hospice and palliative medicine, thereby including emergency medicine training as a recognized pathway to board certification in palliative medicine. Since that time, a new cadre of emergency physicians, with additional specialty training in palliative medicine, has become board-certified in both specialties. Many of these dual-boarded specialists have joined our academic training programmes and have become a driving force to establish higher levels of quality in both generalist and specialty-level palliative care in our EDs. A prudent first step for those considering ED-based palliative care initiatives is to anticipate the likely barriers they might encounter in such an effort. In our work to promote palliative care, we have encountered three