Q&A: COVID-19 pandemic accelerates integration of palliative, ED care

Health care systems have previously acknowledged the importance of — but rarely implemented — strategies for integrating palliative care into ED care, researchers wrote in the Journal of Pain and Symptom Management.

The need to integrate palliative care into EDs has become more urgent amid the COVID-19 pandemic, which has led to an increasing number of seriously ill patients in EDs, Emily Aaronson, MD, assistant chief quality officer at Massachusetts General Hospital and assistant professor of emergency medicine at Harvard Medical School, and colleagues said.

The researchers recently conducted a qualitative study of 52 hospitals to identify innovations in palliative care programs embedded in EDs that emerged during the pandemic. In an interview with Healio Primary Care, Aaronson described these new innovations, their impact on patient care and more.

Q: Describe the new palliative care -ED delivery innovations that emerged during the COVID-19 pandemic. Which ones have the greatest impact on patient care?

A: There were five buckets of care innovations that emerged during our work. One consisted of new models of care delivery; other buckets contained innovations in staffing, new uses of technology, enhanced teaching and education; the last consisted of case identification and task stratification.

To your question about which interventions would have the greatest impact: We did not evaluate the efficacy of these innovations as part of this study. With that said, I believe the work around structural changes — for example, fully embedding a palliative care clinician into the emergency department rather than just increasing education of existing ED staff members — has tremendous potential to make an impact.

Q: How can physicians increase conversations regarding the goals of care?

A: There are some foundational skills and lots of great tools out there to help clinicians that want to have more of these conversations. It’s essential that all of us in medicine feel that we have the language and a structure to help us approach these incredibly important conversations. In addition, there are also structural changes that organizations can engage in to ensure these conversations are happening. And then once the conversations are happening, there is infrastructure that is important to have in electronic health records to ensure the content of the conversation is captured and passed on.

Q: Could these conversations change the trajectory of care? And if so, how?

A: We asked this very question as part of a survey during our study. What we heard was a resounding yes — these conversations do have the potential to change the trajectory of care. We heard stories about ensuring patients have room to reflect on what really matters to them and the clinician helping the patient to create care plans that better align with their goals, such as opting not to have invasive procedures. On the other hand, there were patients that were given the space to reflect on what they wanted and made the decision to have very aggressive care — but with them, their families and the care team confident that they were doing this because it was truly an informed decision aligned with their goals and values. Giving patients the space to articulate what they want and to have that discussion was meaningful and definitely changed patient's care trajectories. We found that, for patients, their families and for the treating clinician, there was this sense of being at peace with knowing that they were providing the highest quality care most aligned with the patient’s goals and values, which was really powerful.

Q: What barriers might health systems encounter when incorporating these interventions? How can these barriers be overcome?

A: Palliative care and subspecialty services personnel are often stretched quite thin, and dedicating someone in the ED to the palliative care role may be challenging for many organizations. With that said, leveraging advanced practice providers or other interdisciplinary team members that may already be in the ED may hold a lot of promise. We are in the process of a randomized clinical trial that is examining the efficacy of social workers trained in this area in leading some of these discussions.

Q: What modifications are needed to adapt the interventions to rural areas ?

A: Technology-assisted palliative care sessions hold tremendous promise for rural areas. All clinicians need is an iPad or telephone into the patient’s room and then let the infrastructure connect patients with the appropriate staff.

Q: Do you think these palliative care- ED interventions will be useful after the pandemic? Why or why not?

A: Absolutely. The clinicians in our study identified some very specific benefits that are pandemic agnostic, like freeing non-ED clinicians for other tasks, helping these clinicians feel more supported, changing the patient’s care trajectory, contributing to clinical education and helping support specific skill acquisitions. These benefits would certainly persist in the absence of the pandemic.

References:

Aaronson EL, et al. J Pain Symptom Manage. 2020;doi:1016/j.painsymman.2020.10.035.

Aaronson EL, et al. J Pain Symptom Manage. 2020;doi:10.1016/j.painsymman.2020.08.007.