GOALS OF CARE IN THE ED

Although not typically seen as an ideal environment to discuss goals of care, the ED represents an important point at which healthcare providers can guide patients in navigating their further management and personal goals related to care.^{Reference Grudzen, Corita and Stone1} In Canada, the experience of dying most often occurs in the hospital, commonly involving a substantial number of interventions and investigations.^{Reference You, Dodek and Lamontagne2} One fifth of deaths occur in an intensive care unit^{Reference Cook, Rocker and Marshall3} while rates of cardiopulmonary resuscitation (CPR) prior to death continue to increase among the elderly population.^{Reference Ehlenbach, Barnato and Curtis4}

QUALITY OF LIFE OVER QUANTITY

Because patients presenting to EDs are increasingly advanced in age and more medically complex, greater clinical skill is required of the ED physician in symptom management and end-of-life care. While hardwired to provide heroic measures in an efficient manner, emergency physicians must also recognize and respect illness presentations where further efforts may not be futile or in keeping with a patient's goals of care. A recent Canadian study found that 80% of older adult patients in the hospital with a serious illness prefer a less aggressive and more comfort-oriented end-of-life care plan that does not include CPR.^{Reference Heyland, Barwich and Pichora5} For many patients, the focus will shift towards maximizing general well-being and comfort, with the value of quality of life outweighing that of quantity.^{Reference Smith, White and Arnold6}

Patients with dementia are at a heightened risk for in-hospital death, and an increasing proportion of the population is dying from advanced dementia. Physicians often under-recognize the terminal nature of the gradual loss of cognition and function seen in dementia, as research demonstrates that dementia patients frequently receive suboptimal end-of-life care, and often burdensome interventions.^{Reference Ouchi, Wu and Medairos7}

Early palliative care can benefit both patients and healthcare systems. At a systems level, incorporation of palliative care into EDs can limit healthcare spending without compromising quality of care. Recent evidence demonstrates that early integration into palliative care can reduce ED visits and hospitalizations by up to 50%.^{Reference Wang8}

USING EFFECTIVE COMMUNICATION STRATEGIES

A number of barriers make engaging in goals-of-care conversations with patients challenging for emergency physicians. Limited time, privacy, and a lack of an established therapeutic relationship compound an already difficult conversation.^{Reference Rogers and Lukin11} Research indicates that emergency physicians also cite challenges in predicting illness trajectory during a brief encounter in the ED.^{Reference Argintaru, Quinn and Chartier12} Despite some prognostic uncertainty, emergency physicians can rely upon effective communication strategies to convey important messages to patients and their families about disease outlook and viable symptom management options. Wang et al.^{Reference Rogers and Lukin11} highlight a method to approach a brief goals-of-care conversation in the ED setting (Table 1).

Table 1. A systematic, 5-minute approach to ED goals-of-care conversations.

Palliative care in emergency medicine offers patients and families support along the entire continuum of care and is best if instituted as early as possible.^{Reference Rogers and Lukin11} Using a simple framework to engage in goals-of-care conversations can make the process more accessible for emergency physicians. Often deferred and addressed later during an admission, it's important to recognize that palliative care can begin in the ED and successfully bridge into inpatient and outpatient services. It can radically improve the way that patients interact with the healthcare system, while enhancing comfort and dignity at the end of life.