Mapping the Future for Research in Emergency Medicine Palliative Care
Key findings
- Members of the Society for Academic Emergency Medicine and the American Academy of Hospice and Palliative Medicine collaborated on a "research roadmap" that suggests priorities for research on integrating palliative care into emergency departments (EDs)
- Some of the foundational work proposed in a previous research agenda has been done, such as describing the population of patients with serious illness in the ED, but much work remains, especially research into outcomes and effectiveness
- New research concerns have emerged that were not previously described, notably those related to disparities in care and the reproducibility and sustainability of interventions and models of care delivery
- Healthcare system decision-makers need a clearer understanding of exactly what palliative care in emergency medicine entails, so they can focus on the highest-yield components and forgo those that are less effective
Well before the outbreak of COVID-19, a few studies documented that the integration of palliative care (PC) and emergency medicine (EM) improves patient-centered care as well as hospital operational outcomes. A consensus panel convened by the American College of Emergency Physicians published a research agenda in Academic Emergency Medicine in 2009.
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Over the past few years, the evidence base about EM PC has increased rapidly. Members of the Society for Academic Emergency Medicine (SAEM) and the American Academy of Hospice and Palliative Medicine (AAHPM) saw the need for an updated framework to focus and prioritize future research.
Emily L. Aaronson, MD, MPH, assistant chief quality officer in the Lawrence Center for Quality and Safety at Massachusetts General Hospital, served as the first author of a "research roadmap" the working group recently published in Academic Emergency Medicine.
Methods
The SAEM Palliative Medicine Interest Group and members of the AAHPM assembled a group of 20 thought leaders with clinical, operational, policy, and/or research expertise in both EM and PC. The panel comprised primary clinicians, clinical researchers, hospital administrators, and one PhD-prepared investigator.
Over 12 months (August 2020–August 2021), the experts worked to identify gaps in the research and key areas for future work. The board of SAEM endorsed their research roadmap, and the research committee of the AAHPM affirmed its value, the committee's highest level of support.
A Framework for Future Investigations
The working group calls on researchers in EM PC to focus on four research domains:
The value imperative for PC in the emergency setting—Healthcare administrators need to understand the value of EM PC for quality, cost, and appropriateness. It will be just as important to investigate the needs of patients, caregivers, and family members—not robustly represented in the research to date—with specific attention to cross-cultural differences and barriers to uptake.
A more nuanced body of work should begin to take shape that explores not only "why PC in EM" but also the question of "what" and "how much" PC is required in the emergency department (ED). Augmenting the limited literature on death in the ED will also be important.
Models of care delivery—Despite more than a decade of research, no model of care has undergone fidelity testing, evaluation of effectiveness, or measurement of sustainability. Increased knowledge of prioritizing different models will help leaders match the right models to the right environments and populations. Domain-specific models also require attention, in observation medicine, EMS services, and telemedicine, for example.
Disparities in EM PC may exist based on race/ethnicity, religion, payer type, age, socioeconomic status, gender identity and sexual orientation, culture, language, physical and cognitive abilities, housing type, or ED location and resources. If so, investigators should determine their magnitude (about access, care delivery, and patient experience), how they may differ between groups, and what the regulatory landscape is that either protect or jeopardizes equitable care and outcomes.
Measurement of impact and efficacy—Researchers must develop conceptual frameworks that will establish clear associations between interventions and outcomes of interest in both EM and PC. This work will have to address the challenge of collecting certain measures in the ED, especially patient-centered ones, and assessing their usability. A figure in the article lists some outcomes and measures of interest.
Existing quality indicators will need to be validated in the ED setting, and it's hoped new indicators with specific relevance to EM PC will be developed.
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