Embedding Palliative Care Physicians in the ED Facilitated Goals of Care Conversations Early in COVID-19

On March 23, 2020, as the COVID-19 pandemic was escalating in Boston, Massachusetts General Hospital created a new service in which palliative care (PC) clinicians were embedded in the emergency department (ED)—physically present there during their shifts—and worked collaboratively with ED physicians.

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This pilot program lasted eight weeks, until May 14, 2020. Juliet C. Jacobsen, MD, DPH, an attending physician in the Division of Palliative Care and Geriatric Medicine at Mass General, Laura A. Petrillo, MD, a physician in the Division, Emily L. Aaronson, MD, MPH, assistant chief quality officer at Mass General, and Jason K. Bowman, MD, clinical attending physician at Brigham and Women's Hospital, report details of its effectiveness in the Journal of Palliative Medicine.

Design of the Program

A PC physician was physically present in the ED seven days a week from 9:00 a.m. to 7:00 p.m. Six PC physicians served in this role.

ED and PC physicians worked together to identify patients to receive ED–PC consultations based on the acuity of presentation, age (patients under 18 were excluded), and burden of comorbidity, as well as previously documented preferences to limit life-sustaining treatment.

The original intention was to focus consultations on patients with suspected COVID-19. However, ED and PC physicians also consulted with other patients who met the aforementioned criteria in the ED during the study period.

PC and ED physicians evaluated patients simultaneously as part of an integrated team, and there was no separate consent process by patients/families before PC consultation. The PC needs addressed during each consultation were left to the discretion of the PC specialist.

Results of the Program

The key findings were that:

• No patient or family declined PC consultation
• ED–PC teams consulted with 159 patients, average age of 78 (range, 25–100), 50% female
• 93 of those patients (59%) had a goal of care conversation documented in the electronic medical record after the consultation; the most common topics addressed were patient/family understanding of the illness (96%), what was most important to the patient/family (92%), and a clinical recommendation (91%)
• ED–PC teams estimated prognosis during 57 of the 93 documented discussions (61%); in the majority of those cases, the prognosis was described as poor (e.g., "incurable," "days")

Proceeding Despite Uncertainty

This pilot study illustrates that goals of care conversations can occur in the ED despite known barriers such as prognostic uncertainty, a loud and chaotic environment, frequent interruptions, variable availability of caregivers, and lack of time, space, and ED clinician training.

Early uncertainty about the prognosis related to COVID-19 was the most notable barrier in this study. In the spring of 2020, it was unclear whether the limited data on mortality reported from other countries could be extrapolated to the U.S. population. In addition, because of delays in obtaining test results early in the pandemic, clinicians usually didn't know whether patients had COVID-19. This demonstrates it is not always necessary to know the exact prognosis to have a prognostic discussion.

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