- Palliative care (PC) and emergency medicine physicians at Massachusetts General Hospital met soon after the COVID-19 pandemic reached Boston and developed a model for integrating palliative care into the Emergency Department (ED)
- Key elements of the model are an embedded PC physician in the ED, an emphasis on rapid case identification, a surge plan and COVID-19-specific conversation guides
- During the first six weeks of the program, the PC team formally consulted on 104 ED patients, and the model was repeatedly changed to address challenges in case identification and the need to tailor PC to the ED
- ED frontline staff have given overwhelmingly positive feedback, expressing appreciation for ''at the elbow'' support with conducting serious illness conversations
The COVID-19 pandemic has exposed the need to integrate palliative care (PC) into emergency departments during a crisis. In a letter to the editor of the Journal of Palliative Medicine, Mark Stoltenberg, MD, of the Division of Palliative Care and Geriatric Medicine at Massachusetts General Hospital, Emily Aaronson, MD, MPH, assistant chief quality officer and attending physician in the Department of Emergency Medicine, and colleagues describe a model they created for embedding PC into the Emergency Department (ED) at Mass General.
Creation of the Model
The group began with twice-weekly calls between the PC chief of service, operational leads in PC and an ED attending who had served as the PC liaison. Within a week, they developed a model that hinges on four elements:
- Embedded physician: A PC physician is present in the ED from 9:00 am to 7:00 pm, has a workspace near the ED team and participates in daily rounds
- Rapid case identification: In addition to ED-initiated requests for consults, the PC physician monitors the ED board and patient charts, then approaches the ED team if a serious illness conversation seems necessary
- Surge plan: A protocol is available for engaging the inpatient PC team to support excess consults when needed
- Conversation guides: Several COVID-19-specific conversation guides were developed for use as teaching tools with ED staff
During the first six weeks of the program, the PC team formally consulted on 104 ED patients. The model was repeatedly changed to address challenges in case identification and the need to tailor PC to the ED.
For example, because family members could not be present, the PC team developed a workflow for sharing telephone calls with the ED team. ED clinicians initiate calls and provide the family with a brief medical update, and then a PC clinician conducts a goals of care conversation.
ED Staff Satisfaction
ED frontline staff report being pleased to have partners in conducting discussions about serious illness. They have given overwhelmingly positive feedback, expressing appreciation for ''at the elbow'' support and the consequent learnings.
As the pandemic continues, the clinicians plan to study the variety of models that emerged organically and build a template that can be easily accessed and applied in the future.
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