How to tell emergency room patients that they're dying.

Quest saw no stomach aches or sprained ankles in Emory's ER that night. Each of her patients was admitted, at least for observation. The three most critically ill patients—the old woman from the nursing home, who turned out to have had a stroke, and the two men with cancer—survived the night. None was steered to hospice. It wasn't appropriate for her patients on that night. Maybe in the future, after another conversation.

No law passed by Congress, or payment change by Medicare, will change the role of palliative care, or the ingrained responses of emergency physicians. But change has nevertheless begun. Since 2007, more than 140 emergency doctors, nurses, social workers, and chaplains have been through a training program that Quest helps run to inject basic palliative expertise into emergency departments nationwide. Other schools and centers and foundations have started similar work. Pilots and partnerships will arise as health reform unfolds. Doctors in the two disciplines are finding and learning from one another.

The default patterns of emergency medicine are the patterns of much of U.S. medicine writ large. Health reform aims to change not only the financing but, to some extent, the culture of care. Reformers want to move away from a system that rewards the quantity of tests and procedures to one centered on the quality of care. They want a system that does a better job of caring for patients with slowly worsening chronic disease. Palliative care, though maligned and misunderstood during the summer of the "death panels," is part of that culture change. The emergency room is one place to start.

Correction, Aug. 5, 2010: This article originally misspelled the name of Chicago's Northwestern Memorial Hospital. (Return  to the corrected sentence.)

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