Can We Get the ED to Think Hospice?

A year ago Kathleen Schneider, M.D., was an emergency medicine physician on the staff of five Milwaukee hospitals. Today she is medical director for VITAS Innovative Hospice Care® of Milwaukee. She knows first-hand that the two fields don’t overlap much. But she also knows first-hand that they should.

The patients most appropriate for hospice, she says, tend to be most inappropriate for the emergency department: the end-stage COPD patient who is rushed to the hospital ED monthly, or even weekly, gasping for breath. The patient with congestive heart failure whose therapies are becoming less effective. The patient with repetitive infections that can’t be habilitated.

“The ED wants to fix things,” Dr. Schneider explains. “They want to save lives.”

But not everything can be fixed, a lesson Dr. Schneider appreciates more as a hospice physician than she did as an emergency medicine physician. “The ED staff is frustrated and the patient is worn out,” she says.

But if the illness can’t be fixed, Dr. Schneider knows there is still much that can be done. It starts with a conversation with the family, and continues, at home or in a VITAS inpatient hospice unit, with intensive symptom management and whatever emotional support the patient and family need. It comes with the promise of no more ambulances and no more emergency departments, but, instead, plenty of communication and understanding by a team dedicated to end-of-life care.

Knowing that ED staffs nationwide are critical to identifying and redirecting repeat ED patients who are hospice-appropriate, VITAS is bringing to emergency medicine physicians and staff, in five-minute sessions if need be, information on what hospice is, who is appropriate and how to make a referral.

“We understand how challenging it is, because of the time constraints,” says Rich Clarke, senior director of market development for VITAS Innovative Hospice Care® of Broward County. “But we will commit to off-hours education, whether at midnight or a 6 a.m. breakfast or something in between. And we repeat it until we’ve seen most of the staff. Because EDs will continue to be overcrowded as long as the same patients keep coming in the doors.”

“The biggest obstacle,” notes Tara Friedman, M.D., “is just getting the ED to think hospice. There are so many people being sent home to die. Or they’re triaged and, if there are no advance directives, admitted to the ICU and intubated. Or admitted to the medical-surgical floor. It’s not palliative care at all,” she laments. “The system is failing these patients.”

Dr. Friedman is medical director of the VITAS program in Philadelphia, where she sees patients in inpatient hospice units on specially designed wings of three Philadelphia hospitals. Several years ago Dr. Friedman noticed that patients were coming to the VITAS unit after several days of aggressive care in the ICU or on a hospital floor. Some were dying quickly—too quickly to benefit from the full menu of services hospice provides.

“Could we help patients whose goal is palliative come right to the VITAS unit,” Dr. Friedman wondered, “rather than after several days of aggressive treatment?” In other words, could she get her host hospitals to think hospice?

Doctors Friedman and Schneider today lead a national VITAS initiative to improve the disposition of terminally ill patients arriving at the ED.

“The emergency medicine physician is often the first to pick up on a patient’s transition from chronic to terminal,” Dr. Schneider says. “The family or the nursing home staff may have seen a slow decline in a patient with dementia or disability. The ED docs can offer a fresh look or see a pattern emerging.”

“And hospice isn’t 9 to 5, it’s 24-seven,” Dr. Friedman interjects. “Nursing home referrals tend to happen at night and on weekends, and we’re there! Our Telecare® system is a virtual emergency department: fully staffed and never closed.”

Dr. Schneider likens a partnership with VITAS to having a social worker in the ED. “When I was an emergency medicine physician, we loved having a social worker,” she recalls, “someone who made phone calls, found rehab beds, talked to families. They complemented the medical care by focusing on issues that could otherwise get too little attention in a hectic ED.

“The ED gets a bad rap,” she says. “People think they’re cowboys, that they don’t care about patient care and follow-up. But they are concerned. Certainly the ED nursing staff can be patient advocates. With their input, we can help their sickest patients, reduce crowding and help in breaking bad news. I would like to tell them, ‘Think hospice; there are all kinds of opportunities!’”