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Palliative Care

Author

Bonnie Marr, MD
Assistant Professor
University of Maryland School of Medicine

Faculty Editor

Rebecca Goett, MD, FACEP
Assistant Professor
Assistant Residency Program Director/Assistant Director for Advanced Illness & Bioethics
Emergency Medicine & Palliative Care
New Jersey Medical School/Rutgers University

Special thanks to our 1st edition writing team

Bonnie Marr, MD
Rebecca Goett, MD, FACEP
Sangeeta Lamba, MD

INTRODUCTION

Description of the specialty
Palliative care (PC) is patient-centered specialized care for those with a serious or chronic life-limiting illness. PC aims to improve patients’quality of life by providing pain and symptom relief as well as spiritual and psychosocial support. Palliative care has been shown to improve quality of life, reduce hospital length of stay, reduce number of repeat emergency department (ED) visits, improve patient and family satisfaction, lessen utilization of intensive care units, and provide overall cost savings to hospitals.1,2

Hospice is a type of health care for patients in the last months of their lives when curative treatments are either not available or no longer desired by patients. Hospice enrollment enables patients to receive comprehensive medical care outside the hospital, including nursing visits, medications, medical equipment, social work, and spiritual support in the comfort of their home or at a hospice facility.Although palliative care can overlap with hospice and the terms are often used interchangeably, palliative care and hospice are not the same. Palliative care may be provided along with curative treatment over an extended period of time. Hospice care, on the other hand, is appropriate for patients with life expectancy less than 6 months.  Hospice also supports patient’s families beyond the death of patient.

History of the specialty/fellowship pathway
Emergency departments are increasingly treating patients with advanced chronic illnesses and those who are seriously ill and dying. Ideally, integration of palliative care should be done by patients’ primary care providers or by dedicated palliative care providers who work alongside patients’ regular providers. However, with the health care system serving an increasing aging population, and considering primary care provider shortages as well as fragmented specialty care, the introduction and implementation of palliative care does not always happen before the patient visits the ED. ED providers are therefore increasingly engaging, developing and incorporating palliative care in the ED for their seriously ill patients.

In 2006 Hospice and Palliative Medicine (HPM) became an officially recognized subspecialty where ten specialties including emergency medicine can obtain HPM certification. The American Board of Emergency Medicine (ABEM) offers a pathway for emergency medicine (EM) trained physicians who complete a Hospice & Palliative medicine fellowship to sit for the HPM board certification. Thus, the EM physician who completes fellowship and passes the boards will become dual board certified in both emergency as well as hospice and palliative medicine. Currently, there are about 115 dual board certified physicians (EM and HPM) and emergency medicine is 6th out of 10 specialties in such dual certified physicians.3

The integrated emergency and palliative medicine discipline in general has shown tremendous growth and garnered increased interest in the last decade. American College of Emergency Physicians (ACEP) has a very active Palliative Medicine section with growing membership each year, in addition to the Society for Academic Emergency Medicine (SAEM) Palliative Medicine interest group. Also, due to increased physician demand, the American Academy of Hospice & Palliative Medicine (AAHPM) has recently established an emergency medicine special interest group. In addition, due to the increasing number of palliative care-emergency medicine research papers, the ACEP Annual Research Forum created a separate submission section for palliative and hospice medicine to be alongside ultrasound, critical care, and other long-standing core content in Emergency Medicine research in 2015. ACEP Now magazine has dedicated pain and palliative care section showing the increasing call to incorporate palliative care into emergency medicine education and practice. It’s a new and exciting place to be!

Why residents choose to follow this career path
Residents choose to follow this career path when they desire to practice emergency medicine as well as hospice and palliative medicine jointly or they may transition to practice as a full-time palliative medicine physician.

How do I know if this path is right for me?
If you are the type of resident who can step back during a clinical shift and put a patient’s ED visit into the context of “the big picture,” this specialty may be for you. If you have a strong interest in improving the care of those who are very seriously ill and/or dying, then this specialty provides the key skills to improve end-of-life care. If you’re an excellent advocate for your patients and actively inquire about their wishes, then you’re already on the path to becoming an amazing HPM physician. Additional avenues of interest include bio-ethics of medicine, symptom management in patients with complex chronic illness where the goal of treatment is focused on relief of symptoms . (Symptom management can include but not limited to pain management, and often includes dyspnea, GI symptoms, agitation, etc.) This fellowship will teach you to become a skilled communicator and you will become the “go-to” person in your department for treating and educating others about caring for the sickest of the chronically sick.  In addition, you will help to identify the patient’s ‘goals of care’ and shine a light on the treatment pathways desired by the patient early in their course, which may help to avoid unnecessary admissions and procedures.

If this interests you, then a palliative medicine fellowship will give you a niche for your future academic career. Having a niche by training in palliative medicine may allow for a varied perspective and an opportunity to balance clinical work with education and research in a less chaotic, less procedure intense, or time-constrained setting. Some physicians want to have these options in their careers so later they can adjust their work-life balance and transition to clinical care in a care setting other than working ED shifts.

Career options after fellowship
HPM fellowship is meant to train you as an independent HPM physician who can run an inpatient unit, palliative care consult service, or become an outpatient palliative care or hospice provider after fellowship. 

Splitting time between departments
After fellowship, some physicians prefer dividing their time between the two departments often with rotating time blocks of ED shifts and inpatient palliative care consult service. Other physicians may want to practice HPM medicine only in the ED. Most EM-HPM physicians are contracted for majority of their time in the emergency department due to the salary difference, in that emergency medicine physicians make more annually. HPM physician’s salaries are more similar to sub-specialists in internal medicine such as nephrology or endocrinology. 

Most EM-HPM dual-trained physicians work in major academic institutions where they teach palliative care and/or do research. These physicians are generally consulted in the care of seriously, chronically ill patients and specialize in alternative treatment pathways other than aggressive resuscitation. Some physicians sit on ethics committees in conjunction to their clinical practice. Others take on the role as hospice medical director.

Being an EM-HPM pioneer, you may need to pave your own way, setting up your schedule/time split and negotiating between the two departments. The best way to do this is to figure out your own personal career goals and compare them with what the institution’s expectations are in terms of clinical hours, salary, teaching, and research requirements for full-time physicians within each department. Past hospitals have hired EM-HPM physicians and allowed them to split their time between two departments; however, other hospitals might not be familiar with EM-HPM providers and will need guidance to how this works. Similar to other subspecialties, you may need to look at the two departments to find the right fit, or have the flexibility for two different institutions.

Academic vs. community positions
Most EM-HPM trained physicians work in major academic institutions that are more comfortable or familiar with providers certified in multiple specialties. As an EM-HPM physician, you most likely will be the point person in your emergency department for faculty teaching or medical education and the collaborating physician for ED based palliative care-oriented projects. If EM-HPM medical education and/or research is concurrent with your future career goals, then choosing an academic environment may be more conducive.

Remember, after fellowship you are an asset, bringing a unique perspective and skill set that is vital to the hospital, so don’t forget this when negotiating! You will lead your emergency department to gain specialized skills and knowledge in hospice and palliative medicine. If there is a program you’re interested in working at after fellowship, send out your CV and take the time to call the director, as some places will not always advertise their job openings. Before accepting, make your goals—such as medical education or research—are clear to both to you and your employer in order to thrive as a supported faculty member that achieves their professional goals.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Currently the ACGME lists 137 hospice & palliative medicine programs.

Differences between programs
Because hospice and palliative medicine involve nearly every specialty, HPM fellowships can be sponsored via different disciplines and departments. Most fellowships span both inpatient and outpatient settings and are sponsored by general internal medicine or family medicine; although, others can be housed within the geriatric, oncology, or anesthesiology departments. Emergency medicine and surgery departments however currently do not sponsor a fellowship program. 

Fellowship directors may hold primary certifications from a variety of disciplines. An example: Emory Palliative Care Center, which is headed by an emergency medicine physician, versus the director of UCSF-Fresno, who is trained in both internal medicine and psychiatry. Be sure to check whether a fellowship’s faculty composition is primarily from the same background or if there is a variety of specialties represented. This can tell you if the faculty have similar interests and goals in research, administration, or education to which you seek.

Older, more established programs tend to have larger faculty, more fellows, and fixed schedule blocks that provide more structure. Smaller, newer programs may offer less structure, but can provide greater flexibility if you want to focus on a particular area, design your own electives, or wish to moonlight in an ED throughout fellowship. Despite some variations, all fellowships regardless of size or departments, require the same basic rotation requirements.

Length of time required to complete fellowship
HPM fellowships are 1 year. Some programs offer additional tracks in research, geriatrics, bioethics, or public health which may require a longer time commitment. 

Skills acquired during fellowship
As an HPM physician, during rotations you will specialize in acute symptom management, running family meetings, and helping to optimize the care of a patient with their loved ones by attending to their medical, spiritual, and psychosocial needs. Patient and family interactions can be intense and time-consuming, but are also very rewarding as you work to honor patients’ wishes while improving their quality of life. This specialty requires patience and good communication skills in order to balance all aspects of care across multiple services (oncology, neurology, surgery, etc.) and settings (such as hospital, home, long-term care etc.) HPM providers are often looked upon as the masters of communication and conflict resolution; adept at resolving difficult clinical decision-making conflicts and solving ethical dilemmas, as well as providing good end-of-life care.

  • Symptom control
    This includes pain control and alleviation of other bothersome and/or difficult to control symptoms experienced by patients with serious illnesses, such as chronic malignancy related pain, dyspnea, nausea/vomiting, fatigue, neuropathic symptoms, etc. Guidance and management of symptoms of the actively dying patient in both inpatient and outpatient settings, such as: delirium, anxiety, dyspnea, etc.
  • Communication skills
    These are critical for conflict resolution and goals of care discussions. You will learn how to do this while simultaneously giving caregiver (surrogates) support. Palliative medicine is an interdisciplinary team sport, including social work, medical chaplaincy, nursing, and advanced practice providers. Communication and leveraging team care is fundamental to palliative medicine.
  • Goals of care
    In addition to being a master of symptom management, it is necessary to be adept at building a realistic view of a patient’s disease trajectory and using this to provide advice regarding the non-initiation or stopping of interventions that are not consistent with a patient’s goals, as well as insuring that the plan of care is clearly communicated, understood, and agreed upon by the patient and their support system.
  • Clinical recognition skills
    Fellows recognize chronic illness or dying trajectories of terminal illness, organ failure, frailty, and sudden illness to help prognostication. They can identify the imminently dying patient, complications of cancer, and cultural and ethical issues surrounding end-of-life and death.
  • Ethical/legal understanding
    Gain knowledge of advanced directives and multidisciplinary team/support systems for chronically ill and dying patients.

Typical rotations/curriculum
Your fellowship will likely be divided into blocks (usually 1 month in length) of inpatient consults or working with patients in a palliative care unit, hospice outpatient visits—typically within a patient’s home, inpatient hospice both acute and long-term care, and electives in pediatrics, geriatrics or interventional pain. 

Inpatient experience will span at least 4 months in duration or roughly 100 hours monthly, although most fellowships do more. Most fellows achieve this experience by working in a palliative care inpatient unit or by participating on a palliative care consultation team or both. ACGME requires fellows to see 100 new patients and follow at least 10 patients longitudinally across settings by the end of fellowship.

Patient homes and long-term facilities: Fellows conduct home hospice or home palliative care visits with members of the interdisciplinary team which often include nurses, chaplains, social workers, etc. and attend any interdisciplinary case conferences for their patients. This can be completed as a separate clinical block or spread out over several months, i.e. every Thursday you do home visits with the team. Fellows must have 25 minimum hospice home visits Fellows’ long-term care experience should comprise a a minimum of one month or total 100 hours and provide access to meaningful care of patients on either a consultation team or a hospice or palliative care unit.

Ambulatory practice setting: This is usually outpatient palliative medicine clinic that runs weekly although it varies from institution to institution. You must attend clinic for at least 6 months during fellowship.

Elective: Fellows must spend at least 1 month or equivalent of elective time in a clinically relevant field. Electives may include ethics consultations, geriatric medicine, interventional pain management, medical psychiatry, pediatrics, HIV clinic, medical oncology, radiation oncology, pulmonary, cardiology, neurology clinics, or other experiences determined to be appropriate by the program director.

Fellowship scholarly activity: This must be completed during fellowship and can be a research project or quality improvement project involving hospice & palliative medicine

For more information, consider reviewing ACGME requirements.

Board certification afterwards?
Yes. The written boards are offered every other year and there is no HPM oral exam component. Recertification is every 10 years. In 2016, the pass rate for the first-time takers was 92%. 

Average salary during fellowship 
Most fellows receive a PGY-4 or 5 level salary.

PREPARING TO APPLY

How competitive is the fellowship application process?
The application process is currently evolving as both the awareness and popularity of the specialty are growing. The fellowship was available through the NRMP Match in 2015 for the first time. Match data is now available through the NRMP: http://www.nrmp.org/wp-content/uploads/2018/02/Program-Results-2014-2018.pdf. Some geographic locations or larger metropolitan areas tend to be more competitive.

Requirements to apply
Candidates should be allopathic or osteopathic physicians in good standing and anticipated to graduate from one of the approved disciplines previously described-this includes emergency medicine. 

Research requirements
There are no strict criteria regarding research. However, it is encouraged and there are an abundance of research opportunities within the field. 

Suggested rotations to take during residency
It is generally recommended that applicants rotate with the palliative medicine service within their institution or participate in an elective in HPM if available. This shows prior exposure to the clinical scenarios relevant to the practice of HPM and demonstrates interest. 

Suggestions on how to excel during these rotations

  • Access the literature and introductory texts before and during the rotation to foster a greater depth of understanding for the evidence guiding palliative care in clinical settings.
  • Demonstrate dedication to becoming an adept communicator. Fundamental communication skills lead to success when discussing goals of care and during family meetings; however, they take time to develop. It is clear when a resident is making an effort to practice these skills. Consider reviewing VitalTalk at for useful tips.
  • Be a team player. This skill set is important in all areas of medicine and just like it is part of being a successful emergency physician, this will help you learn how to garner the best care for the patient while including all members of the team such as: social work, chaplaincy, case management, pharmacists, and other learners.

Should I complete an away rotation?
Away rotations are particularly useful if you are hoping to match at a specific program. A stellar job will certainly help you stand out when rank lists are made later in the year. This will also allow you to experience a program firsthand that you may be interested in to try them out, too!

What can I do to stand out from the crowd?
As mentioned above, a positive rotation will go a long way towards standing out. Since there is so much opportunity for exploration of research and education in HPM, participating in projects that align with your interests can be worthwhile. It will also show a longitudinal interest in the topics surrounding HPM (whether this is through publications, volunteerism, committee work, or involvement in education) and a longstanding commitment to the field. 

Should I join a hospital committee?
There are many opportunities for overlap between the goals of a hospital committee and HPM. The important element is finding one that you’re passionate about and would like to continue to explore. This is not necessarily a requirement as much as a suggestion since it will show a dedication to the field. Some suggestions include the ethics or pain management committee.

Publications other than research
Since there is so much opportunity for integrative medicine and possibility for the use of medical humanities within HPM, most clinicians have an appreciation for other forms of publication. For example: creative writing, poems, play-writing, and medical narratives. However, this is again what feels true to your own personal interest. The important aspect is building a link between these and your interest in HPM. 

How many recommendations should I get? Who should write these recommendations?
In general, at least three letters of recommendation are preferred with at least 1-2 letters from within the field (although this is not a requirement, per se). As always, a letter from the residency Program Director is encouraged, as well as from faculty whom you have worked with extensively. Additional letters may be from mentors/supervisors of research or special interest projects. If an elective or away rotation was done in HPM, a letter from HPM faculty is highly recommended. Overall, the key is to choose people who can translate your unique skill set to HPM.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, the key is to demonstrate interest and a ‘trail of breadcrumbs’ that led you to this new path. In these cases, it is beneficial if clinical experience can be directly tied to HPM exposure. If this is challenging it may be wise to look for alternative avenues, such as gaining permission to shadow the in-house HPM consult team, that may provide clinical exposure.

What if I’m a DO applicant?
The AAHPM and NRMP websites both state that DO physicians are considered candidates for the match in HPM. 

What if I am an international applicant?
Refer to the NRMP website as far as application procedures apply.

There may also be some institutional variation, and therefore one may want to contact programs of interest prior to applying in order to find out their procedures and practices. 

APPLICATION PROCESS

How many applications should I submit?
This is largely dependent on the applicant’s geographic area of interest, confidence in their candidacy, and number of programs that feel like a good fit. Because the HPM fellowship has only gone to the Match relatively recently, there is not a lot of real data to work with. It may be most beneficial to discuss the exact number with an advisor based on your performance-to-date and geographic area of interest. In general, more is better than less to provide you with an adequate pool to choose from and make-up for possible programs that may not offer you an interview. 

How do I pick the right program for me?
It is important to consider future next steps when choosing a program as geographic location may determine your next career move. In addition, if a specific institution would be your dream job, it may be useful to train there. Geographic location and accessibility to your support system may be a consideration given the financial constraints many trainees have graduating from residency and still earning a salary commensurate with a PGY-4 as well as the stressors involved with starting a new training program. 

Get to know the people in the program! Are fellows happy? Do the faculty seem supportive? Are there opportunities for exploring your interests? Many of the same rules apply as when you interviewed for residency.

Explore if there are opportunities available specifically for EM trained graduates. Inquire about moonlighting if you want to keep your skills fresh while in training. Many programs are looking to expand their presence in the ED and inquiring about consult numbers from the ED will give insight into the type of exposure HPM staff have to ED patients.

Common mistakes during the application process

  • Assuming all programs are alike especially in palliative care. Every program will have a slightly different range of experiences that they have to offer. It is important to identify what your career goals are and to check to see if the places you have interviewed align well with them. It also will insure your ultimate happiness at the place you match with.
  • Not asking enough questions!
  • Make the programs work for a spot on your rank list! Write a list of your top priorities in a program and check to see if the program meets your standards. You are interviewing them as much as they are interviewing you. Remember: this is the launching pad for the next stage of your career.

Application deadlines
HPM participates in the NRMP Medical Specialties Matching Program. Check the timeline for your specific fellowship route and review the NRMP Fellowship Applicant Checklist.

Tips for writing your personal statement
A strong personal statement will describe the journey you took in deciding to pursue an HPM fellowship, highlight your personal qualities that make you an ideal candidate, and does not serve as a carbon copy of your CV. As with all personal statements, it is important to have a good hook as your personal statement will be one of many that a person may read and you want to stand-out. If possible describe personal experiences, research, and key cases that contributed to your decision. 

The conclusion is also important. Put it all together for the reader and connect how all of these pieces fit to make you an ideal candidate.

Is this a match process?
Yes. HPM uses the NRMP MSMP. Designing a rank order list is a similar process to the one used for residency. 

What happens if I don’t obtain a fellowship position?
Open slots are posted on the AAHPM JobMart for candidates to review. It is also beneficial to review the procedures on NRMP regarding applying for unfilled slots. Most importantly, you should review your application with the HPM program director or elective director available at your institution and assess what needs to be improved upon for future application cycles. You also may want to consider further exposure to HPM through electives or mentoring that is available within your institution 

INTERVIEW PROCESS

How do I stand out from the crowd?
Be yourself.

Practice: Try to rehearse with a faculty member in HPM to help yourself prepare for typical interview questions (see below for examples) and polish your answers. This will help your responses sound natural and come easily to you, so you won’t freeze on interview day. The program generally wants to get to know you and already knows your credentials. They are looking for a good fit.

Don’t be afraid to highlight your achievements. Your goal is to show that you will be an asset to the program and to insure the program will be supportive of your interests. It is helpful to demonstrate this connection for the interviewer and help them see what you will bring to the program and why you’re unique.

Show you are truly interested in their program. If you’re making the investment of interviewing at the program, then it should be a place you’re seriously considering. Take the time to read about what makes their fellowship unique and use these facts to highlight your interest.

What types of questions are typically asked?

  • Why are you interested in a hospice and palliative medicine fellowship after completing a residency in EM? Provide an example of a case you participated in that influenced your career path.
  • Describe how your personal skills will help you navigate challenges in palliative care (i.e. difficult family meetings, challenging interactions with the primary team for the patient, etc).
  • What do you hope to be doing in 5 years?
  • Why are you interested in our program; what brought you here today?

How many interviews should I go on?
As previously mentioned, this is difficult to approximate given the Match process has only been used for a couple of years. Since some programs are more ‘Emergency Medicine friendly’ it would be beneficial to investigate in advance how many prior graduates are from EM and if they are seeking EM candidates (this also obviously is beneficial when you select programs to apply to). Also, it would be wise to add an EM-friendly program in for every program you’re not sure of. In general, assess the strength of your application, your goal geographic area, and consider your comfort level both financially and for insuring a spot. It is never considered wise to apply to a single program. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Quill TE, et al. AAHPM’s Primer of Palliative Care. 6th ed. Chicago, IL: AAHPM; 2014.
  • McPherson, ML. Demystifying Opioid Conversion Calculations. Bethesda, MD: ASHP; 2009.
  • DeSandre PL, Quest TE. Palliative Aspects of Emergency Care. Oxford University Press, Oxford, UK. 2013

Important skills to practice while in residency to prepare for fellowship

  • Run a family meeting with a fellow or attending present for back-up.
  • Consider practicing goals of care discussions when appropriate. Remember, palliative care is part of the Choosing Wisely campaign for EM.
  • Try opioid conversion practice problems using some of the texts listed above and while supervised by an attending if you’re able to do an HPM elective.

Tips on how to succeed as a fellow
Be a self-directed learner. This absolutely will serve you well regardless of what specialty becomes your ultimate career. Recognize gaps in knowledge or questions represent opportunities for learning. Don’t accept the answer, “We do this because this is the way it has always been done,” and look for supportive literature to show the evidence that supports our practice patterns. Learn from your attendings and ask them to explain their thought process. This may be your last chance to work in an environment where your education is a top priority! Take advantage of it and try and pick-up pearls from a variety of sources along the way. Consider including local EM leadership in adding support for HPM within the hospital and take the lead on consults coming from the ICU and ED. Show off the amazing skill set that you have developed through an EM residency. Be a team-player. HPM is a team sport like EM with many moving parts. It is important to always recognize and value the skill sets offered by case managers, social workers, chaplains, nursing, and other specialties that are an essential part of the palliative team.

CONCLUSION

Additional resources

Podcasts:

Journals:

  • Journal of Pain and Symptom Management
  • Annals of Emergency Medicine
  • Academic Emergency Medicine
  • JAMA Oncology, especially January 2015
  • Journal of Palliative Medicine
  • Journal of Emergency Medicine
  • Western Journal of Emergency Medicine

Clinical Resources/Websites/Blogs:

National organizations

  • ACEP: Palliative care section
  • American Academy of Hospice & Palliative Medicine (AAHPM): Emergency Medicine Special Interest Group (SIG)
  • Society of Academic Emergency Medicine
  • Center to Advance Palliative Center
  • Palliative Care Network of Wisconsin

Conferences

  • ACEP Scientific Assembly
  • AAHPM Annual Meeting
  • Education in Palliative & End-of-Life Care (EPEC)
  • EMTalk, powered by VitalTalk
  • Center to Advance Palliative Care (CAPC) National Meetings and Webinars

How to find a mentor
Establish a mentor early and connect with him/her often to ask questions and receive feedback. Mentors to consider include your program director, palliative care director, or other palliative care physicians at your institution. The ACEP Palliative Care Section has begun a mentoring program and has an EMRA representative that facilitates EM-PC networking and mentoring. 

Remember, at this time there’s a limited number of dual-certified EM-PC physicians in this young sub-specialty who are able to advise and mentor. It is important that you seek out mentors from both outside and within your institution in order to start the search process and begin networking early.

References

  1. Penrod J, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
  2. Ciemins E, Blum L, Nunley M, et al. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med. 2007;10(6):1347-1355.
  3. American Academy of Hospice, Cosponsoring boards. “Number of Certified Hospice and Palliative Medicine Physicians by Cosponsoring Specialty Board.” Certified HPM Physicians | AAHPM, 15 Dec. 2015, aahpm.org/hpm/number-certified.