Study recommends better care for terminally ill patients in emergency rooms

By Steve Tokar on August 04, 2010

Alexander Smith, MD, MS, MPH

Hospital emergency departments need to be better adapted to the needs of terminally ill patients who are increasingly seeking palliative care in the emergency room, according to a study led by a physician at the San Francisco VA Medical Center.

“At first blush, palliative care in the emergency department sounds like a contradiction in terms,” says lead author Alexander Smith, MD, MS, MPH, a palliative medicine physician at SFVAMC and an assistant professor of medicine in the Division of Geriatrics at the University of California, San Francisco. “Palliative care seeks to treat symptoms and bring comfort to patients. In the emergency room, the goals are patient stabilization and disposition – either admission to the hospital or release back into the community.”

Smith notes that other studies have shown that emergency departments have become “common sites of care at the end of life,” yet emergency room crowding has increased severely over the past 20 to 30 years. “Waiting times to see an emergency department physician have increased over that time as well, which has left many patients frustrated, uncertain, waiting, and in pain.”

The study authors observe that in spite of mounting interest in improving palliative care in emergency departments, little research has been done in this area.

Smith says the goal of the study, which appears in the June 2010 issue of the “Journal of Pain and Symptom Management,” was to “understand more about the experience of patients with very serious illness who were seen in the emergency department.”

The authors conducted in-depth interviews with 14 terminally ill patients who were admitted to emergency departments at two academic medical centers, and with seven of the patients’ family caregivers. All but one of the patients lived at home, and many were receiving medical treatments intended to prolong life or relieve symptoms.

The researchers found that, in many instances, emergency department visits resulted from what Smith calls patients’ and caregivers’ “inadequate preparation to deal with pain or other distressing symptoms, such as nausea and vomiting, at home.”

The implication, he says, is that “we need to better prepare patients and their caregivers to take care of pain and other symptoms of terminal illness at home or in other outpatient settings. There has to be greater recognition of their need, and ability, to know how to manage these symptoms without having to go to the emergency room.”

In the emergency department, the patients and their caregivers reported feeling frightened, uncertain, and anxious. “This is certainly understandable, given the long waiting times, noise, and activity level in emergency departments,” observes Smith. “Patients wonder, ‘What’s going on, what are the results of this test, why am I even getting this test, why am I waiting so long?’”

The study authors recommend that emergency department personnel learn and practice better patient-communication skills.

Pain management was also an issue, says Smith. “It’s hard to generalize from a study of 14 patients,” he cautions, “but there appears to be room for improvement. Some patients reported excellent pain relief, but others said they had to wait a long time to receive pain control, or that their pain went unrecognized.”

Smith concludes, “What this paper suggests is that we need better training of emergency department physicians and nurses in symptom management, pain management, and communication.”

Co-authors of the study are Mara A. Schonberg, MD, MPH, Jonathan Fisher, MD, Daniel J. Pallin, MD, MPH, Susan D. Block, MD, Lachlan Forrow, MD, and Ellen P. McCarthy, PhD, MPH, of Harvard Medical School.

The study was supported by funds from The Julie Henry Fund at Beth Israel Deaconess Hospital and the National Institute on Aging.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.