Integrating Palliative Care Into the Emergency Department During COVID-19

When the first wave of patients testing positive for COVID-19 arrived at the Massachusetts General Hospital Emergency Department (ED), there was an immediate recognition of the need to incorporate palliative care services into the ED.

In palliative care, a division at Mass General that specializes in caring for people with serious illness, the approach to treatment aims to alleviate the suffering of patients and their families by assessing and addressing their physical, psychosocial and spiritual symptoms—critical to this work is understanding their goals and values. When coupled with the efforts of the emergency team, whose focus is to move quickly to identify any imminent life threat, palliative care proved to be an invaluable asset in the ED.

Integrating Emergency Medicine and Palliative Care

In an effort to integrate the two systems in a timely way, a group of Mass General physicians—under the leadership of Vicki Jackson, MD, chief of palliative care, and David Brown, MD, chief of emergency medicine—came together to rapidly conceptualize and implement a model of care delivery that embedded a palliative care physician in the ED full time.

“When the COVID-19 pandemic began, we almost immediately noticed a critical gap related to a lack of palliative care in the ED,” says Emily Aaronson, MD, associate chief quality officer, emergency physician and a member of the team that spearheaded the integration of palliative care in the ED at Mass General. “Emergency clinicians, providing care in crisis situations, do not always have the dedicated time, let alone the skill and training, to provide palliative care.”

In emergency medicine, Dr. Aaronson explains, the reflex approach to care is often intensive and invasive, as the goal in the ED is to quickly treat the patient’s condition.

“Palliative care physicians do really critical work to make sure that patients and families have the space and time to really reflect on, and communicate, their goals and values. It is a tremendous service for patients and their families,” she says.

Tailored Care Based on the Individual

Among the many services that palliative care physicians provide to patients, the ones that proved most consequential in the care of those with COVID-19 included:

• Understanding the individual patients’ values, priorities and goals in order to construct care plans tailored to reflect their wishes
• Integrating input from key clinicians who know the patient well, such as the patient’s primary care doctor, oncologist or nursing home clinician
• Communicating with patients’ families, providing important information and offering support
• Discussing spiritual needs and making arrangements to fit those needs
• Supporting the mental and psychological health of the patient and their family
• Managing and mitigating symptoms of respiratory distress
• Virtually connecting patients with their loved ones to minimize the impact from the inability to visit in person

Moreover, the positive impact of the presence of palliative care extended beyond the patients and to the emergency physicians.

“As emergency physicians, we are often trying to interpret patients’ wishes based on truncated, time pressured discussions,” says Dr. Aaronson. “With palliative care communicating with patients, and then working with us to help us understand the patient’s story and goals, we could feel more secure that the care we were providing was right by the patient. When we were providing incredibly invasive, aggressive therapy, we felt more at ease that this is what the patient wanted. And when we were not, we could feel confident that it was because that was not what the patient wanted.”

The Approach to this Sub-specialty Integration at Mass General

The model to embed palliative care in the ED was spearheaded by a group of palliative care champions including the palliative care chief of service, operational leads in palliative care and an emergency medicine attending who had served as the liaison. Within a week, they developed a model consisting of four key elements:

• Embedded physician: Assignment of a full-time palliative care physician in the ED
• Rapid case identification: The standard partnership between the ED and palliative care before COVID-19 was for the ED physician to request consultations on a case-by-case basis. In this new model, the palliative care physician partnered with the ED to help identify patients with serious illness that might benefit from their involvement
• Surge plan: An established protocol for working with the full palliative care team in the case of an influx of patients in the ED and, ultimately, an increase in required consultations
• Conversation guides: The development of COVID-specific conversation guides to use as teaching tools with ED staff

“We are moving away from the idea of ‘palliative care patients’ and ‘non-palliative care patients,’” says Dr. Aaronson. “The services that the palliative care team can provide are really appropriate for any patient with a serious illness which, truly, includes many of our patients in the ED. If you are seriously ill and in the ED, we should be giving you and your family the opportunity to express your goals and values.”

Building a Sustainable Model of Embedded Palliative Care in the ED

“It was not until COVID that we had a burning platform. All of a sudden we had this imminent and undeniable need to do it, to build this model,” says Dr. Aaronson. “Moving forward, we hope it will be scaled. Although it will look a little bit different, it will continue to have many of the same elements.”

One element is a dedicated palliative care clinician in the ED to manage these conversations about serious illness and help emergency physicians identify the patient’s goals and values, she says.

Now in the wake of the COVID-19 peak, Dr. Aaronson says the team is conceptualizing this new, permanent model that integrates palliative care in the ED in a way that sustains the knowledge and experience gained during COVID-19 and continues to place the patient at the center of care.

The team recently shared their experience of this model in the Journal of Palliative Medicine.