Patients come to the emergency department at all stages of their illnesses, seeking medical care, emotional comfort, and improved quality of life. For a growing subset of chronically ill patients, care at the emergency department should not only include life-prolonging interventions traditionally associated with a visit to the ED, but routine care should also include early palliative care intervention.

Palliative care, as defined by Quest et al., “is the physical, psychological, social, and spiritual care provided to patients from diagnosis to death or resolution of a life-threatening illness” [1]. In the emergency department, palliative care can take many forms—from allowing family to witness the resuscitation of a loved one, to discussing a patient’s goals for care. For patients to benefit from care that is truly in-line with their stated beliefs and goals, healthcare providers need to be equipped to start the conversation with patients and their families.

This month’s case opens a discussion about palliative care in the emergency department. Medical readers are asked to consider how they approach patients and families about palliative care in addition to thinking about the role palliative care can play in their practice of medicine. Patient readers are asked to reflect on the case and any similar healthcare experiences they have had to share their insight with healthcare providers looking to improve care for others. For a greater introduction to palliative care in emergency medicine, be sure to listen to and take a look at the Improving Palliative Care in Emergency Medicine (IPAL-EM) project here .

The Series

Inspired by the highly successful MEdIC series , What Do You Say? is a case study series that explores difficult patient education scenarios when communication matters most. Every month, a hypothetical case will be posted with questions for discussion. After a week of community input, relevant experts will provide insight for the community to consider and a curated review of the discussion with expert opinions will be disseminated. Have a difficult patient education scenario that you think would make a great case? Contact me via the contact page or send a tweet to @skobner .

The Case

“I can tell something is on your mind, what’s wrong?” asks Dr. West, the emergency department overnight attending.

Malai, the junior resident, was a little upset about the case she was presenting:

“Mrs. Floyd is an 87-year-old woman with a history diabetes, myocardial infarction, multiple strokes, and peripheral vascular disease who was sent to the ED from her nursing home for evaluation of an infection of her left leg. She has been bed-bound, non-verbal, and totally dependent on nursing staff for two years since her last major stroke. Currently, she receives nutrition through a gastrostomy tube and is normally incontinent of urine and feces.

“Today, she is only responsive to painful stimulus with a pulse of 108 BPM, BP 100/70 mmHg, temperature of 38.4°C, SpO2 of 94% on room air, and a finger-stick glucose of 325 mg/dL. On exam, her left leg is edematous, erythematous, warm at the knee, with gangrene extending from her toes proximally to her foot. Apparently no one had noticed her foot until today. Surgery is definitely going to need to take a look at her.”

“You seem upset,” Dr. West interjected, “is it because of concern about her code status?”

“The patient has no DNR in place,” Malai answered, “but facility transfer paperwork indicates that the patient has two adult children. I called them both, because they had not been notified that their mother was in our department. They are on their way to the ED. One daughter told me her mother was clear that she ‘did not want to be on any machines’ when she was verbal. I figured I could talk to her about that more when she arrives soon.”

Dr. West leaned forward in his chair. “Good idea. First, lets get to work on labs, consultations, and getting antibiotics on board. I think Mrs. Floyd and her family would benefit from a palliative care consultation, but it’s up to us to start the discussion. When Mrs. Floyd’s daughters arrive, what do you plan to say to them?”

You are in Malai’s position, what will you say?

Some of the medical aspects of this case were based off a case study by Lamba S, et al. [2].

Questions for Discussion:

  1. How do you initiate the discussion about palliative care with patients and families? In this case, how would you approach Mrs. Floyd’s children to describe her condition, prognosis, and care options?
  2. How do you clarify statements like “she did not want to be on any machines” surrogate decision makers, or explain resuscitative options to patients?
  3. What do you say to help families begin the bereavement process; what resources do you utilize to help families in this time of need?
  4. As a patient or family member, what advice can you give to the healthcare providers taking care of Mrs. Floyd? What is most important to you in this conversation?

Next Week

Come back for a curated community commentary of the discussion as well as three expert responses to the case provided by:

Dr. Eric Widera

Expert 1

Eric Widera, MD

Dr. Widera is the Director of the Hospice & Palliative Care Service at the San Francisco VA Medical Center and Program Director for the Geriatrics Fellowship at UCSF. He is also a co-founder of GeriPal, a Geriatrics and Palliative Care Blog, as well as ePrognosis, an online set of prognostic calculators for the elderly.

Dr. Claritza Rios

Expert 2

Claritza Rios, MD

Dr. Rios is board certified in both Internal Medicine and Emergency Medicine and currently the Associate Clinical Professor in the Division of Hospital Medicine and Palliative Care Program at the University of California, San Francisco.

Meredith Hurston

ePatient Expert

Meredith Hurston, ePatient

Meredith Hurston is a QA Technologist and Patient Safety Data Coordinator for the Department of Pathology at Johns Hopkins who has over 20 years experience advocating for her mother, who suffered from diabetes. Additionally, she owns M Squared Healthcare Consulting Agency, under which she operates The Empowered Mocha Patient Blog as an online healthcare resource for the African-American Community.

Discuss the case in the comments section below or by tweeting with #WDYS

  1. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94-102. PMID: 19185393 .
  2. Lamba S, Desandre PL, Todd KH, 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):264-70. PMID: 24286714 .