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Viewpoint: Palliative Care Belongs in the ED

Article From Emergency Medicine News 

By Dan Morhaim

We are the first generation in history to have a significant role in the care we will receive as we approach the end of life. Approximately 80 percent of us will die from a chronic or degenerative disease, and we or those we designate will have to make treatment decisions

Medicine, in the days before antibiotics, bionic body parts, advanced imaging, and effective cancer treatments, only had comfort and support to offer patients with serious illness. But doctors and patients increasingly face difficult choices as medical technology advances, and these are choices that can differ dramatically for individual patients depending on their values, situations, and preferences.

Complex questions arise: Is the physician's primary duty to cure disease or to ensure the highest quality of life for his patient? When do a treatment's side effects outweigh its benefits? Who makes that call?

Most of us have seen the unfortunate situation where an aggressive care plan cured the disease but left the patient so weakened that he never recovered. The balance of cure versus quality of life is a delicate one. The health care team should provide information and expertise, but it is the patient who ultimately must decide fundamental questions.

Two mechanisms can help sort out these common but complex situations: palliative medicine and advance directives.

Palliative medicine, according to the Center to Advance Palliative Care (see FastLinks), places emphasis “on intensive communication, pain and symptom management, and coordination of care. It is appropriate at any point in a serious illness, and can be provided at the same time as treatment that is meant to cure.”

Until recently a palliative care consult was usually requested only when all hope for cure was gone and no further treatment options were available, and this is still too often the case. A friend with advanced breast cancer who was suffering severe side effects from chemotherapy recently asked for a palliative care consult. Her oncologist rebuffed her request saying, “You're not ready for that yet.” She received essentially little or no help for her pain and anxiety.

The principle of attending to a patient's symptoms and quality of life is employed in less extreme situations although it might not be called palliative care. When we set a broken arm in the emergency department, we prescribe pain medication and suggestions for how to get through daily life with one's arm in a cast. The pain relief and care suggestions may not directly affect the speed with which the bone knits, but we all know how important a person's comfort and peace of mind are to his healing and overall health.

We are seeing benefits beyond what anyone might have predicted for serious illnesses. An August 2010 article, “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer,” noted surprising results when palliative care was introduced early in the care plan. (N Engl J Med 2010;363[8]:733.) “Early palliative care led to significant improvements in both quality of life and mood,” the authors noted. “As compared to patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.

The “timely introduction of palliative care may serve to mitigate unnecessary and burdensome personal and society costs,” they wrote. In other words, patients had better outcomes, and less money was spent. That's a good deal under any circumstances.

The advance directive also addresses the challenges of end-of-life care. A form for this is free and recognized in every state. Whether considered in medical, legal, financial, spiritual, or emotional terms, the exercise of completing a living will and naming a health care agent in case of incapacity helps individuals, families, and their physicians make the best choices for their specific needs. Unfortunately, far too few of us complete advance directives, though it's clear that 100 percent of us are going to die.

Advance directives are often suggested by estate planning lawyers, but research shows that people prefer to have this information provided by their physicians. We need to make this a normal part of primary health care, and emergency providers routinely need to ask for advance directives or to offer the resources to complete them where appropriate.

No discussion about health care is complete without addressing cost. Expenses related to end-of-life care will only increase as our population ages and medical advances allow people to live longer. More than 25 percent of Medicare is spent on end-of-life care, and the costs to Medicaid and private insurance are equally staggering. Those of us on the front lines witness this daily.

Money will be saved if expensive, futile, and often painful “care” is foregone. But it will be saved the right way by promoting palliative care and advance directives, by relieving painful symptoms and by respecting the wishes of individual patients. This is health reform in the best sense, achieved through open and honest communication between doctor and patient. Let's work together to make that standard of care.