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

Health and medicine explained.
Aug. 4 2010 12:51 PM

We Can't Save You

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

How should emergency room doctors treat patients with terminal illnesses? Click image to enlarge.
How should emergency room doctors treat patients with terminal illnesses?

On television, the emergency room patients beat the odds. Their hearts get shocked back to life. Their organs get sewn up. They awaken to a handsome young physician's dazzling smile.

In real life, one in 500 ER patients—200,000 a year—dies under the bright lights of the emergency rooms. Another 500,000—3 percent—die during hospital stays following emergency treatment. Countless patients learn, from a doctor they have never seen before and may never see again, that they have fatal diseases. Others get treated, aggressively and repeatedly, for dangerous flare-ups in conditions like heart failure or emphysema without anyone having the time or the skills to explain that the chronic disease they have been living with is now the chronic disease that they are slowly dying from, a scenario Atul Gawande explored in his recent New Yorker piece on what doctors can do when they can no longer cure.

The ER is not an easy place to come to these realizations or assess their consequences. A handful of physicians are trying to change that. Doctors like Tammie Quest, board-certified in both palliative and emergency medicine, hope to bring the deliberative goal-setting, symptom-controlling ethos of palliative care into the adrenaline-charged, "tube 'em and move 'em" ER. Palliative/emergency medicine collaboration remains rare, but it's growing as both fields seek to create a more "patient-centered" approach to emergency care for the seriously ill or the dying, to improve symptom management, enhance family support, and ensure that the patient understands the likely outcomes once they get on that high-tech conveyer belt of 21st-century emergency medicine.

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Coming on duty for the 4-to-midnight shift at Emory University Hospital's emergency room in Atlanta, Quest noticed a 94-year-old woman with advanced dementia and a black eye. She had fallen two, maybe three, times in the past couple of days. Her nursing home did what nursing homes do reflexively: It called an ambulance. The elderly woman flinched at the gentlest touch. She recognized the "man with the kind face" at her bedside but no longer recalled that William Mitchell was her son. Quest addressed him kindly. "What do you want for her? What are your goals?" Mitchell first replied practically, noting, "I have power of attorney. She's not a person who wants to live forever." The rest came from the gut: "I want her to be back over [at her nursing home] tonight and be OK."

Emory is not the only hospital exploring the intersection of palliative and emergency care. At the Bronx's Montefiore Medical Center, a palliative care nurse is now stationed in the ER, where many of the community's poor receive their only health care. At Chicago's Northwestern Memorial Hospital, emergency physicians have learned to summon the palliative care cavalry for complex cases, and they say that interaction has improved their own ability to deal with death in the ER. *

The patients these doctors and nurses want to reach don't all need the technological wizardry of emergency medicine. They need someone who can control pain, delirium, or shortness of breath and who knows how to break bad news. Someone who, as Quest put it, understands the gap between emotional expectations and medical realities and can help the family define—and the medical team understand—the goals of care. And do it fast: "You can't clog up the ER," Quest says.

"The first hours in the [emergency department] are when determinative decisions are made about disposition and plan of care, and palliative care could be contributing to those decisions," Diane Meier, the director of the Center To Advance Palliative Care, wrote in the Journal of Palliative Medicine. Palliative care in the emergency department can shore up pain and symptom control and help the family marshal resources, whether the patient opts for the ICU, hospice, or something in between.

Joe Stewart, 73, a lung cancer patient, had complex needs. "I have pain, I can't swallow. Everything I eat or drink tastes like crap, and I've been sleeping two days straight," Stewart told Quest. His fiancee, Starlett Graves, recited all of Stewart's many medicines by name, time, and dosage. ("She's good!" Quest exclaimed to Stewart. "What are you waiting for? Marry her!") His chemo, part of a clinical trial, had ended a month earlier. They were hoping for good news. But that night, tests showed a blood clot in his lung. Quest explained that he would have to remain in the hospital a few days. A fuller conversation about treatment options and implications would wait. This was enough to absorb, for now.

Quest was deeply concerned, too, about a gastric cancer patient, also 73. He had been diagnosed at another hospital a month ago, and either the oncologists had not explained his dire prognosis or the family had not taken it in. Now his kidneys had shut down. If the ER team could restart them, he might have two or three good months. If not, he might not make it until morning. The family expected a cure.

Quest was supposed to be off duty by then, but that family tugged at her. They needed "the conversation." Maybe not the whole, prolonged, complicated version. But a start. She pulled back the curtain and took her patient's hand. "In case things get worse, what do you want?" He couldn't whisper more than an uncertain word or two. She turned to his wife and grown children. "It's even harder if we don't talk about it." She explained the facts of life—or the facts of death—in the emergency room. When a death occurs, the ER rescues, resuscitates, revives. "We want to make sure we're doing what you want. And we're not doing things that you don't want."

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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