# 246 Emergency Department Management of Hospice Patients

FAST FACTS AND CONCEPTS #246 (pdf)

Authors: Sangeeta Lamba MD, Tammie E Quest MD, David E Weissman MD

Background  Patients enrolled in hospice programs will occasionally be transported to the Emergency Department (ED).  Emergency medicine training focuses on life-prolonging measures and may fail to address hospice as a system of care.  This Fast Fact provides information for clinicians practicing in EDs on management issues when a hospice patient arrives. Fast Fact #247 discusses initiating hospice care from the ED.

Why do Hospice Patients come to the ED? ED providers should never assume that arrival in the ED equates a desire for aggressive/life-prolonging treatment.  Even when a patient/family requests such services, an assessment is needed to understand the concerns that prompted a shift in care goals.  Frequently such requests arise from fear about the dying process or guilt about prior medical decisions to limit life-prolonging treatments.  Common triggers for an ED visit include:

  • Stress/inability to cope with impending loss of life.  This may be expressed as a request to start a life-prolonging treatment previously used and discontinued (e.g. chemotherapy) or never begun (e.g. renal dialysis).
  • Poor symptom control.
  • Malfunction/loss of a support device such as a gastrostomy tube.
  • Failure of the hospice program to provide timely patient support and communication.

Management Guidelines

  1. Notify hospicestaff as soon as possible.  Under the Medicare Hospice Benefit, hospice agencies are legally/financially responsible for the patient’s plan of care and all medical costs related to the terminal illness. See Fast Facts # 82, 87, 90.
  2. Determine the trigger for the ED visit, pay attention to not only the distressing signs and symptoms but also the emotional and psycho-social issues. Involve social service and chaplaincy personnel early if needs are identified.  Contact the palliative care team for consultative advice if needed.
  3. Treat distressing symptoms.  See Fast Facts for specific symptom treatment guidelines.
  4. If deterioration is imminent and rapid decisions are needed regarding the use of life-sustaining treatments (e.g. intubation for respiratory failure) a focused discussion around goals of care must occur in the ED
    • Determine the legal decision maker if available and review any completed advance directives.
    • Complete a rapid goals of care discussion (see Fast Facts #223, 224, 225, 226, 227).
    • Make recommendations.For example, ‘According to what you want for [the patient], I would/would not recommend….’
  5. If the patient is actively dying(see Fast Fact #3) assess for cultural/spiritual needs; assure privacy and endeavor to identify if there are any preferred locations a patient can be safely transferred to to die (e.g. back home; to a private hospital room).   
  6. Laboratory tests/diagnostics should be limited or withheld until discussion with the patient’s hospice care team.  Testing should be based on patient-defined goals of care. Generally, low burden, non-invasive methods which may reveal reversible pathology or clarify prognosis should be used first.
  7. Therapeutic modalities should be based on patient-defined goals of care rather than automatic‘ED indications’ (e.g. antibiotics for pneumonia should only be used if they meet a patient or surrogate defined goal of care).
  8. Disposition should be planned after discussion with hospice staff based on the patient’s goals.  Returning home or a direct admission to an inpatient hospice facility may be the best disposition rather than hospital admission.  At times, hospices can arrange 24h professional support in the home for patients with difficult to manage symptoms who wish to remain home (‘continuous care’ – see Fast Fact #87).
  9. Notify the inpatient palliative care service if the patient is to be admitted to the hospital.  Hospice agencies may revoke a patient’s enrollment in hospice care if care goals have changed, or may continue a patient under hospice care during an admission for palliation (see Fast Fact #87).

Summary     Patient-centered care for hospice patients may be enhanced by emergency clinicians who acquire skills to quickly adapt to a supportive role in the care of a terminally-ill patient.  Recognizing common triggers for the ED visit, using a multi-disciplinary approach with early involvement of hospice, social services and palliative team consults may assist in providing optimal care for ED patients under hospice care.

References

  1. Chan GK. End-of-life and palliative care in the emergency department: a call for research, education, policy and improved practice in this frontier area. J Emerg Nurs. 2006. 32(1):101-3.
  2. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med.  2009. 54(1):86-93.
  3. Reeves K. Hospice care in the emergency department. J Emerg Nurs. 2008. 34(4):350-1.
  4. Lamba S, Quest TE. Hospice care and the Emergency Department: rules, regulations and referrals. Ann Emerg Med.  2011; 57:282-290.

Author Affiliations:  University of Medicine and Dentistry of New Jersey, Newark, New Jersey (SL); Department of Veterans Affairs, Emory University School of Medicine, Atlanta, GA (TEQ); Medical College of Wisconsin, Milwaukee, WI (DEW). 

Fast Facts and Conceptsare edited by Drew A Rosielle MD, Palliative Care Program, University of Minnesota Medical School and Fairview Health Services, and are published by the End of Life/Palliative Education Resource Center at the Medical College of Wisconsin. For more information write to: drosiel1@fairview.org.  More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc.  

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only.  Lamba S, Quest TE, Weissman DE. Emergency Department management of hospice patients.  Fast Facts and Concepts. October 2011; 246.  Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/Documents/ff_246.htm.

Disclaimer:Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used. 

ACGME Competencies: Systems based practice, Communication

Keywords: Systems/Policy, Communication