Palliative Care vs. Hospice: The Role of the Emergency Physician

“All patients with serious illness should have access to quality palliative care.” — Center for Advancement of Palliative Care

The role of EM in the house of medicine has traditionally included preserving and prolonging life. We have contributed to high end-of-life costs and placed significant financial, emotional, and professional burdens on patients and family members. In one study, 77% of patients seen in the emergency department in their last month of life were admitted to a hospital in the last month of life, with 68% of those dying in the hospital.¹

Meanwhile, those enrolled in hospice at least a month before death rarely visited the emergency department.²

Palliative Care
Several studies have indicated that involving palliative care earlier during a patient’s hospitalization has numerous advantages. One study found that having a palliative care provider in the ED may reduce costs. Another study demonstrated the personal benefits of early implementation of palliative care, including improving patients’ quality of life, longer median survival estimates, and reduced length of stay. By receiving palliative care, patients and their families experience a decrease in the burden of medical costs and an increase in their quality of life.^{3 4,5 6} These services are available to patients through Medicare Part A, Part B, and most private insurance providers.

Palliative care services are defined as patient-centered care for any patient, irrespective of age, with a severe or chronic life-limiting illness, not necessarily based on a patient’s prognosis.⁷

An analysis by the Institute of Medicine Committee on Approaching Death in 2011 indicated that 11% of health-care costs went to those with a life expectancy of less than 1 year.⁸ For those whose life expectancy was greater than 1 year, 40% had persistent, year-after-year high spending.

Palliative care specialists best serve this population of patients and their families. For those living with chronic illness, palliative care services can be available for decades. Specifically, patients who benefit from palliative care are those with functional dependency, frailty, cognitive impairment, caregiver exhaustion, social vulnerabilities, and multiple comorbidities. Patients may receive this service concurrent with disease treatment from disease onset.

Palliative care specialists help patients understand their underlying disease, provide disease-mediated and treatment-associated symptom management, and facilitate goals-of-care discussions. They provide social support for patients and families, answer questions regarding symptom management and new symptom onset, and facilitate therapy sessions with social work teams as well as spiritual guidance. Caregivers also have physical, emotional, and practical needs assessed and supported.

Patients qualify for this service under fee-for-service billing under Medicare Part B or contracts with payers using various payment models. Complex illnesses are chronic with multi-year trajectories, periods of crisis, and emotional and physical exhaustion for patients and their families. Understanding the services provided by palliative care and the impact palliative care can have on meaningful patient outcomes can significantly improve quality of life while minimizing emergency department or hospital utilization.

Hospice
Hospice is a model of palliative care for patients whose natural progression of disease(s) is expected to result in death within 6 months. Patients may benefit from this specialty service if curative treatments are unavailable or no longer desired.⁹

Enrollment allows patients to receive comprehensive medical care outside the hospital, including nursing visits, medications, equipment, social work support, and spiritual support. Patients and families on hospice care also have access to a 24/7 hotline for questions and support, as well as opportunities for family respite care. Other facilities include inpatient hospice units, where patients can be directly admitted, that provide a good option for rapid ED disposition. Admission criteria for general inpatient hospice require that patients have uncontrolled pain or symptoms that cannot be managed in the standard hospice setting, or respite care for family members. Whether at home or in inpatient facilities, hospice teams maximize the opportunity for patients to spend their last moments in their chosen setting, instead of the one chosen for them.

Barriers
Barriers to providing patients with palliative care services exist due to limited availability in emergency departments and inpatient admissions.

Despite the growth of palliative care programs in larger hospitals, a tiny fraction of eligible patients receives these services, often due to limited resources and staffing. As a result, primary care and ED providers must be comfortable with advance directives and goals-of-care conversations.¹⁰

Historically, primary care providers have led these conversations at the initiation of referrals to disease-modifying treatments. In that setting, patients are not yet suffering from serious illnesses causing loss of quality of life.

Emergency physicians can be more present in discussing disease processes and patients’ goals of care, but barriers exist in the fast-paced ED environment; physicians often shoulder multiple responsibilities, making it challenging to hold such ongoing conversations with the patience and compassion that patients seek. As a result, such conversations often begin during admission or in the actively dying process.

Additional barriers include limited understanding of the prognosis for both patient and provider, time constraints, anxiety surrounding such conversations, and inability to coordinate with specialty teams and family resources. If emergency physicians are able to initiate conversations and provide early intervention, then the ED presents a unique opportunity to substantially improve quality of life and capture patients who may benefit from palliative care services.

In 2013, ACEP and the Choosing Wisely Campaign engaged patients suffering from serious illnesses with conversations about palliative care and hospice services. ED presentations of seriously ill patients open up opportunities to discuss code status, care goals, and the role of palliative care in subacute disease management.

For admitted patients, early consultation with palliative care can facilitate multidisciplinary communication. Patients discharged home may benefit from referrals to outpatient palliative care or social workers and case management teams to minimize recurring ED visits. This especially applies to patients who qualify for hospice services.

For critically ill patients, emergency physicians’ hyperacute conversations regarding goals of care are crucial in changing the direction of treatment.¹² Both ACEP and EMRA offer toolkits to recognize patients with serious illnesses and improve goals-of-care conversations. Exploring patients’ and families’ prior experiences with determining their primary goals and understanding hospice care — and explaining how their goals align with hospice — can be an effective way to introduce a potential transition in care to one of these services.

Palliative care providers exist to give expert consultation and assistance with complex decision-making conversations; however, emergency physicians and primary care providers carry initial palliative care conversations, especially early in the disease course. Clinicians should use this paradigm to provide clear communication, caregiver support, well-coordinated care, and symptom management, particularly in patients with serious illnesses.

References 

1. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). Jun 2012;31(6):1277-85. doi:10.1377/hlthaff.2011.0922
2. Miller DG, Vakkalanka JP, Swanson MB, Nugent AS, Hagiwara Y. Is the Emergency Department an Inappropriate Venue for Code Status Discussions? Am J Hosp Palliat Care. Mar 2021;38(3):253-259. doi:10.1177/1049909120938332
3. Wang DH, Heidt R. Emergency Department Embedded Palliative Care Service Creates Value for Health Systems. J Palliat Med. Nov 11 2022;doi:10.1089/jpm.2022.0245
4. Grudzen CR, Richardson LD, Johnson PN, et al. Emergency Department-Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol. May 1 2016;2(5):591-598. doi:10.1001/jamaoncol.2015.5252
5. Wu FM, Newman JM, Lasher A, Brody AA. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med. Nov 2013;16(11):1362-7. doi:10.1089/jpm.2012.0352
6. da Silva Soares D, Nunes CM, Gomes B. Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review. J Palliat Med. Jun 2016;19(6):601-9. doi:10.1089/jpm.2015.0369
7. Hawley P. Barriers to Access to Palliative Care. Palliat Care. 2017;10:1178224216688887. doi:10.1177/1178224216688887
8. Aldridge MD, Kelley AS. The Myth Regarding the High Cost of End-of-Life Care. Am J Public Health. Dec 2015;105(12):2411-5. doi:10.2105/ajph.2015.302889
9. 2020 Edition: Hospice Facts and Figures. August 2020. Accessed 4/13/23. www.nhpco.org/factsfigures
10. Growth of Palliative Care in U.S. Hospital 2022. 2022. Accessed 4/13/23.
11. Lynn J. Living long in fragile health: the new demographics shape end of life care. Hastings Cent Rep. Nov-Dec 2005;Spec No:S14-8. doi:10.1353/hcr.2005.0096
12. Hsu HS, Wu TH, Lin CY, Lin CC, Chen TP, Lin WY. Enhanced home palliative care could reduce emergency department visits due to non-organic dyspnea among cancer patients: a retrospective cohort study. BMC Palliat Care. Mar 13 2021;20(1):42. doi:10.1186/s12904-021-00713-6