1. International Palliative Care Network Lecture Series 2015 - Master Lecture under the auspices of the European Association for Palliative Care

2. Emergency Department and Palliative Care Sangeeta Lamba MD, MS HPEd

3. Associate Professor of Emergency Medicine Associate Dean of Education Rutgers New Jersey Medical School, Newark, New Jersey lambasa@njms.rutgers.edu

4. About the Presenter Board certification: Emergency Medicine (EM), Internal Medicine, Hospice and Palliative Medicine Interests and research Teaching and assessing palliative care skills Communication skills in trauma and EM Palliative Care milestone development for EM residency training Chair- Elect Palliative Medicine section, American College of Emergency Physicians-ACEP, Chair Emergency Medicine SIG/Forum -AAHPM Integration of palliative care into EM practice Center to Advance Palliative Care; IPAL-EM advisory expert

5. Conflict of Interest or funding source None

6. Goals and Objectives Describe the importance of and challenges to ED palliative care List US models of ED palliative care Identify generalist and specialist levels of ED palliative care List ways to help jump start the process of ED integration of palliative care Identify quality measures that track outcomes of integration initiatives

7. The Emergency Department (if applicable)

8. The Emergency Department Clinical Culture Challenges Resuscitation based Practice is high distraction High medico-legal risk Currency is speed National pressures on the ED around quality “core measures ” (time to…) Opportunities Receptive to new ideas (Domestic violence, smoking cessation, HIV screening) Pride in patient advocacy; Safety net for all Problem Solvers; Will try to “handle it”, not bother others Collaborative team culture Focus on symptom management (pain, dyspnea)

9. Why palliative care in the ED? Often initial point of contact with patient Opportunity to intervene during a crisis Key decision points in patient’s health care trajectory Life-sustaining treatments are initiated Hospice and Palliative medicine is a subspecialty of Emergency Medicine 1.Lamba S, DeSandre P, Todd KH, Bryant EN, Chan GK, et al., Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration, J Emerg Med, 2014, 46(2):264-270. 2.Lamba S, Mosenthal, AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine, J Emerg Med, 2012, 43(5):849-853. 3.Lamba S. Early goal-directed palliative therapy in the emergency department: a step to move palliative care upstream, J Palliat Med, 2009, 12(9):767.

10. Choosing Wisely "Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit…. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can benefit select patients resulting in both improved quality and quantity of life. http://www.acep.org/Clinical---Practice-Management/ACEP-Announces-List-of-Tests- As-Part-of-Choosing-Wisely-Campaign/

11. Models of ED-Palliative Care in the US Intensity of ED Engagement in Palliative Care Examples: Quest T, Herr S, Lamba S, Weissman D. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative, Ann Emerg Med, 2013, 61(6):661-667

12. Generalist vs Specialist ED Palliative Care Generalist level palliative care Provided by the ED practitioner and refers to basic skills and competencies required of all ED physicians (Communication, symptom control, decision making) Will likely include ED clinician considering: What is the clinical status and prognosis? What are the burdens or benefits of treatments? What are the patient’s/surrogate’s wishes?

13. Generalist level ED Palliative Skills 1.Determining illness trajectory and prognosis 2.Communicating sad, bad and difficult news 3.Interpreting/formulating advance care plans 4.Symptom management (pain and non-pain) 5.Withholding/withdrawal of non-benefecial treatments 6.Managing the imminently dying patient 7.Understanding ethical and legal issues at end-of-life 8.Spiritual and cultural competency 9.Managing the dying child 10.Allowing family presence during resuscitation Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities, Ann Emerg Med, 2009, 54(1):94-102

14. Specialist level ED Palliative Care – Difficult to control symptoms (pain and others) – More complex decision making or conflict – Management of an actively dying patient – Withdrawal of non-beneficial treatments (e.g. help with terminal extubation) – Bereavement support (e.g. after sudden deaths in victims of trauma or death of a child) – Challenging dispositions requiring care coordination (hospice, palliative care unit etc.)

15. Screening for ED palliative care Patient Criteria (Triggers) Newly Identified ED Patients For Early Palliative Care Consultation 1. Older Patients with comorbidities: The frail elderly with advanced dementia and those transferred from long term care facilities 2. Advanced malignancy 3. Neurological conditions: Devastating acute neurological events such as stroke and intracranial bleeds and chronic conditions with declining/poor QOL 4. Resuscitations and Cardiac Arrest (Traumatic and non-traumatic) 5. Organ failure: Advanced stages of organ failure such as advanced Congestive Heart Failure, end stage COPD and Liver Disease George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2015 Aug 31. pii: S0885- 3924(15)00444-3. doi: 10.1016/j.jpainsymman.2015.07.017. (2015)

16. Screening for ED palliative care Patients under Hospice or Palliative Care visit EDs Why do patients under hospice care visit ED? 1.Poor symptom control 2.Malfunction or loss of support devices (tracheostomy or gastrostomy tube) 3. Stress, fear and inability to cope 4.Conflict about life-prolonging treatments 5.Competing philosophies of approach to care between care giver and patient 6.Caregiver fatigue 7.Automatic ingrained response to perceived distress 8.Failure/inability to communicate or address patient needs in a timely manner 9.Equipment failure (example home oxygen or nebulizer machine) 10.Call initiated by hospice (unable to provide that aspect of care or patient is a ‘full code’) Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals, Ann Emerg Med, 2011, 57(3):282-290. Lamba, S., Quest, T. E. and Weissman, D. E., Emergency department management of hospice patients #246, J Palliat Med, 2011, 14(12):1345-1346.

17. Screening for ED palliative care Surprise question, “Would you be surprised if this patient were to die in …..” This integrates co-morbidity, clinical, social and other factors Choice/ Need The seriously ill patient makes a choice for comfort care only There is a special need for palliative care due to complex end of life issues such as malignant bowel obstruction. Clinical indicators – Specific indicators of advanced disease Imminent worsening of condition. Interventions such as ventilator and pressor support are not likely to benefit patient or change outcomes.

18. “Triggers” or Screening to identify patients for specialized palliative care Time to screen1-2 min Who performs screening ED triage nurse (preferably no additional ED resources) Staged process1st tier ED screen process Detailed assessment if needed conducted by other qualified personnel such as social worker or palliative care nurse Target population  Elderly >65 and/or  Chronic Life limiting illness Suggest each ED identify target based on the population served example cancer, heart failure Prognostication‘Would you be surprised’ questions George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2015 Aug 31. pii: S0885-3924(15)00444-3. doi: 10.1016/j.jpainsymman.2015.07.017.

19. “Triggers” or Screening to identify patients for specialized palliative care Special considerations  Functional status of patient  Caregiver/social support  Frequent ED admits and hospitalizations (Set time and definitions) Assess outcomes of screening process 1. Completion rate of tool and number screen ‘positive’ 2. Referral to specialized in-hospital or community resources (palliative team, hospice care) 3. In those who screened ‘positive’ and are referred to specialized or community services  Nature of intervention by specialized service  Frequency of repeat ED visits and hospitalizations  Time to disposition and discharge  Adequacy of symptom control  Patient and/or caregiver satisfaction

20. 4 Things to do to Jump Start ED Palliative Care Identify your ED Palliative Care “Champions” Review the existing literature Identify your ED and institutional resources Develop a plan for a needs assessment Lamba S, Quest TE, DeSandre P, Lawson R. Integrating Palliative Care In The Emergency Department: How To Jump-Start The Process. Concurrent Didactic Presentation Session for the national assembly, American Academy of Hospice and Palliative Medicine. San Diego, California, March 2014.

21. Consider the ED needs Frequent ED visits or readmissions? Inappropriate ICU utilization? Suboptimal patient/family satisfaction with care in advanced illness? Delay in consultation?

22. Outcome Measures

23. Metrics Three categories of metrics are recommended: – Operational – Clinical – Customer service

24. Sample Measures Data 1. ED LOS-hours 2. ED disposition status Death in ED Admit-ward; ICU; PCU Hospice Long term care Home 3. Death within 72 hours of hospital admission 4. Hospital total and average daily direct cost 5. ED referrals for palliative care consultation in ED 6. ED referrals for hospice

25. Customer Satisfaction Metrics % of live ED discharges who reported they were fully informed about their condition/treatment options % of surrogates/families who report excellent end-of-life care after ED death % of patients reporting excellent pain/symptom management

26. Keys to success: Understand the ED Culture and Collaborate/Make it Easy Understand the culture Spend a half-day in the ED shadowing staff. Review ED symptom management policies and protocols. Gather with key ED staff for a meeting to learn common needs around care of the seriously-ill Assist ED staff to develop or facilitate ED processes (bereavement pamphlet, debriefings for difficult scenarios)

27. Keys to success: Collaborate/Make it Easy Invite ED staff to round with the palliative care team. Develop collaborative protocols for potential unmet palliative needs of ED patients Provide an in-service on community hospice resources. Provide a pocket card with palliative care team members’ contact information.

28. ED and Palliative Care