Culture Eats Strategy for Breakfast: Reflections on Wang (DOI: 10.1089/jpm.2019.0251) Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients in the Emergency Department

Dear Editor:

We commend the authors of “Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients in the Emergency Department (ED).¹” Communication between palliative medicine (PM) and emergency medicine (EM) providers is critical to ensure that optimal care is provided to seriously ill ED patients.

However, we wish to highlight the cultural differences between the specialty “tribes” of EM and PM. As an EM physician and PM fellow, I have witnessed and participated in culture clashes that occur periodically between our tribes. Even when EM and PM providers agree that the patient will benefit from a palliative consultation, conflicts may arise due to nuances and mismatched expectations. Therefore, these tips offered by the authors are insightful to help bridge our cultural gap.

Although the focus of the palliative consultation is the patient, the primary stakeholder is the requesting EM provider.² EM providers are measured and tracked largely based on their efficiency, patient satisfaction, and lengths of stay; outcomes of which can affect insurance reimbursement, employment, and provider income. The logistical workflow pressures that EM providers face cannot be underestimated.

For instance, when hospice-appropriate patients are identified by EM providers, arranging a direct ED discharge to hospice can be challenging and time consuming. The authors correctly point out that an assessment of symptom needs, caregiver support, and insurance status is necessary to determine the optimal level of hospice services. Expediting a disposition for hospice-appropriate patients requires complex coordination of multiple stakeholders including case management and hospice liaisons. This process can be cumbersome, especially when EDs are not organized to provide these services seamlessly. When seriously ill patients need hospice referrals off-hours, EM providers may encounter challenges getting a timely response from community agencies such as hospice. The authors proposed an ED observation unit for these patients to assist in facilitating arrangements. Such units could increase lengths of stay and boarding times. Boarding causes ED crowding and is a national problem that is harmful to patients.³ Moreover, the busy, noisy, and fast-paced ED environment may not be conducive to the peace and comfort of actively dying patients and families.

The authors have proposed solutions to help forge successful partnerships between our two tribes, such as internal champions, automatic protocols, and communication style changes. One important solution that should not be overlooked is EM resident education, which can help bridge this cultural divide. Ideally, this education should begin early in EM residency. Studies have shown that there is a paucity of PM education in EM residency curriculums.⁴ EM residents have consistently indicated that they would like more PM education.⁴ By teaching these “tips” to our EM colleagues during the formative years of residency, we can elevate all future EM physicians to be ED champions of PM.

Finally, we suggest that palliative clinicians might consider “shadowing” EM clinicians in their organization. By spending time in an ED clinician's shoes, palliative care providers can truly immerse themselves in the local ER culture, learn their social norms, build trust, and form collegial “intertribal” relationships.