How long have you been an emergency physician, and can you describe the most rewarding and most frustrating aspect of providing care for elderly patients with many medical problems? An 83-year-old woman with mild dementia and multiple other medical problems presents with a broken hip after a fall. Her eldest daughter is present and is a health care proxy and tells you her mom never wanted surgery. Orthopedics is at the bedside telling the daughter her mom needs to have surgery, or she will never walk again.
Is this a common case in the ED? What problems do these cases cause? How do you handle it? How do you deal with the patient and the family? Did you turn to other resources, such as a primary doctor, social worker, or nurse? If so, how was the conversation between the specialist, the family, and yourself? Were there challenges in such conversations?
A cachectic 66-year-old Chinese male with diffusely metastatic stomach cancer who speaks no English is brought in by his daughter who tells you he has had persistent vomiting and has been moaning in pain. But the daughter emphasizes that her father is unaware of his diagnosis (refer to 2. questions a–d). Palliative care is focused on the relief of pain, and suffering and is not limited to end-of-life care. It can be delivered at the same time as curative and life-prolonging therapies.
Have you ever called a palliative care consultation or other kinds of consultants for cases such as the ones we’ve mentioned? What has been your experience with palliative care consultation teams?
Where do you see opportunities for your hospital’s ED and palliative care service to work together? When can palliative care be helpful? For what kinds of cases could a palliative care consult help you with patients and families? If ED physicians want to consult with a palliative care physician or team at your hospital, what are the challenges that need to be addressed? In your hospital, where do you see barriers or problems?
What about the role of the primary doctor: could a palliative care consult take place in the ED without notifying them? What about the specialists, for example, if the patient is being cared for by oncology? What about administration? What other people would need to agree to support these consultations? What about medical-legal issues? What about the logistics of a palliative care consultation, availability of consultants, or other logistical challenges?
When you think of the mission of the ED and your role as an ED physician, how, if at all, does palliative care fit in? As more older adults with multiple medical problems visit EDs, how, if at all, do you see your role changing?
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