Integrating Palliative Care in the Emergency Department with David Wang

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we have David Wang, who’s joining us from San Diego, beautiful country down south, where he is an emergency medicine physician, palliative medicine physician and director of the palliative medicine service at Scripps Health. Welcome to the GeriPal podcast, David.

David: Excited to be here.

Eric: Great, and I’m excited for the topic of how to work with emergency room physicians and clinicians to integrate palliative care. I think we had a better title that we came up with, but that’s the one that I remembered. But before we get into that topic, David, do you have a song to lead us off on this podcast?

David: How about a Take Me Home?

Alex: Take Me Home, Country Roads.

Eric: Are you going to sing with Alex?

David: I think we’re going to be singing together.

Alex: All right. Here’s the chorus. [Singing]

Alex: Well we inverted some lyrics, changed some chords, but we got the general idea.

David: I’m just following you.

Alex: It’s a good start to a GeriPal podcast.

Eric: So, why that song? Any particular reason? Just like it?

David: I love that song.

Eric: All right.

David: Every time I see a street performer, I just got to like stand and watch that.

Alex: Yeah. Instead of Country Roads, that was Take Me Home Country …. yeah, well. The song is called Take Me Home Country Roads in defense, but the lyrics go, “Country roads take me home.”

Eric: This is how we roll on GeriPal podcast.

Alex: That’s right. This is how we roll.

David: A little dyslexia is okay.

Alex: Yeah, it’s all right.

Eric: So, what was that official title that we agreed on? It was the …

David: Joining Forces with The ED.

Alex: There you go. Joining Forces with The ED: How to Improve Palliative Care and Emergency Medicine Integration. Integration? Co-management? Something.

David: Collaboration.

Alex: Collaboration.

Eric: You got to look up the source.

Alex: Something like that.

Eric: We’re going off track with this podcast. Let’s start off right after the song again.

Alex: No, that was good.

Eric: No.

Alex: We’re going to keep all of that. What are you talking about? That’s the best. David, you trained here, right?

David: I did.

Alex: Where were you before you did? And by training here, you did your palliative medicine fellowship here?

David: Yeah, fellowship here, and I was at residency at Stanford.

Alex: At Stanford. So, you’ve been in several different health systems.

Eric: Scripps, Stanford, UCSF.

David: Yeah, and then a med school at UMass.

Alex: At UMass. So this is a bunch of different health systems, and you’ve had the opportunity to work in palliative medicine and emergency medicine in these different environments?

David: That’s right, yeah, and Kaiser as well.

Alex: And Kaiser, too. So, tell us about how that background piqued your interest in this integration of palliative medicine, emergency medicine.

David: Well, it’s kind of cool to see, over time, how things have really evolved in this dialogue and the ED around the perceptions of palliative care. When I started down this road maybe about 10 years ago, really, nobody was talking about this. You’d get some raised eyebrows and maybe a real puzzled look or maybe more colorful remarks. And starting about five years ago, the American College of Emergency Physicians, as part of their first set of choosing wisely initiatives, put palliative care on the map for the ED. And since then, things have really taken off. Everywhere I’ve gone, the question has really changed from, “Why should we think about this?” to more, “That makes sense, but how do we do that? How does that make sense for us in the ED, not just bringing your upstairs knowledge here, but really making it actionable for the daily practice of emergency medicine?”.

Eric: So, why should we do this? Why is it important?

David: It’s hugely important. Everybody comes into the hospital through the ED. The ED is a major gateway into the health care system. I think something like three quarters of people come to the ED in their last month of life and at least half in their last six months of life. What happens in those first few hours, maybe even minutes, really changes their trajectory of care. You know, whether they get committed to an ICU, when they get introduced into the palliative care continuum.

Alex: So, were there any like particularly motivating stories of patients you’ve cared for that made you realize, sort of crystallized for you, you know, “this is important. We need to do a better job of this?”

David: Oh absolutely, and this is like a daily occurrence in the ED. I remember even as a med student having patients with unsurvivable brain bleeds, being brought to the ICU, where there’s really no dialogue around anything but the overly optimistic scenario. Or even as a resident for intubating an ALS patient their first intubation, and the emotional weight of that understanding, what we might be coming downstream of that. In those moments, it’s tough to really think about what sort of downstream care and experience you’re committing a patient and a family to in the ED, but in many ways, we are really kind of like the gatekeepers of that decision and what that’s going to look like for them in the months to come.

Eric: And, do most ED clinicians have extensive training in palliative care during their residency or other training period?

David: It’s very variable.

Eric: Oh that was better than I thought.

Alex: Yeah.

Eric: I thought you’d say no.

David: Can’t say, “No.”

Eric: I’ll take variable.

Alex: It used to be none.

David: It used to be none. I think though, like I was saying, more and more people are asking, “How do we do this?” And it’s always easy to train a new generation than to train everybody else who’s already out there in practice. That being said, we recently actually just published a paper in Academic Emergency Medicine Training about palliative care milestones for ED resident education, also, for continuing education, for current providers, part of our LSA. Last year, one of the five articles that every ED doc was asked to read by the American Board of Emergency Medicine was about palliative care and the ED.

Alex: Really?

David: So there’s definitely attention being paid to this, but, as we all know, culture change takes a while.

Alex: We should have a link to that article. Who wrote that article? Do you remember?

David: Jan Shoenberger, down at USC, was the lead author.

Alex: Great.

Eric: What was in the article? What did they talk about?

David: Mapping out … Well it was expert consensus panel on what milestones, based on the ACGME milestones for different residencies, what those would look with a palliative care lens, for the ED. It was written all by practicing emergency physicians, also with experience in palliative care.

Alex: That’s great. I didn’t know we’d come so far. I used to do research in this area. Actually, that study you quoted about half of patients seen in the emergency department, in the last I think it was six months of life, that was one of my early pieces of research in this area.

Eric: It’s still there.

Alex: It’s still there.

Eric: I always remember Alex studying for the palliative care boards and a question came up that you got wrong on the boards, and the citation was one of your articles.

Alex: Yeah, it’s like, “No. Smith et al.”

Eric: You got your own question wrong.

Alex: Well if I can forget the song lyrics to Take Me Home, Country Road, which I’ve sung only a billion times, I could definitely get my own research backwards too.

David: Well you convinced me on it.

Alex: So I’m glad to hear we’ve moved beyond the why is this important, and there’s buy-in from the professional societies. So, I remember back when I was doing this research, there were training barriers. There was lack of training. You’re saying there’s more training now, but there are also sort of like attitudinal barriers that a lot of people who’d gone into emergency medicine said, “I went in to cure, to act, to save people, to rescue in that moment”. And when somebody comes in, and they’re DNR, or they’re enrolled in hospice, or their plans are aligned with comfort, then I don’t know what they’re doing in my emergency department.

David: There’s that sense of, “I’m here to save lives” and it’s not uncommon. I remember walking to an ED, one of the ones I work in as per diem. And they said, “Oh here comes the morphine doc, everyone hide your patients”. And unfortunately, that’s probably not an isolated narrative to me. Other ED and palliative care trained docs probably have that same experience, but I do want to think that that attitude is changing. I know what you’re talking about, and I think there was a paper maybe about five years ago that was trying to tease out what palliative care meant to emergency providers.

There’s still quite a bit of conflation between palliative care, hospice and comfort care. And sometimes, we are on the other side of spectrum, or DNR patients get less care than they should. More often than not, there’s still a fear of legal ramifications of doing less than the most possible for patients in those moments of uncertainty.

Alex: Yeah, that’s key, the legal aspects, the fear of litigation, because emergency… Is there some data, like, what are the most sued medical specialties? I would guess emergency medicine is up there near the top.

David: I think that unwanted crown goes to OB/GYN, unfortunately.

Alex: OB/GYN. Okay, but you got to be somewhere up there, close second. So, I can understand why that habituation, being sued would make … it’s the chagrin factor reacting to your last bad experience. It’s sort of like it trains you to act cautiously. In this case, that means erring on the side of prolonging life, acting aggressively. Is that sort of the implication?

David: There is part of that. When there’s uncertainty, when so for instance, how does a DNR patient end up intubated in the ICU? When you think about the cascade of events, at least that was a POLST or MOLST form ever completed? If it was completed, did EMS ask for it? Did EMS bring it? Did the emergency physician then asked EMS for it, did the emergency physician interpret it correctly? So many things can happen in those few minutes that leads to a completely awry kind of trajectory of care. That being said, what I’ve noticed, at least in my own experience talking with a lot of younger emergency physicians is, while of course we collectively practice under a dogma of common sense and understanding that we live in a highly litiginous environment, at the same time, people are very motivated to want to do the right thing for patients.

There’s very few celebrated resuscitations of elderly people, with significant comorbidities. And so, the comment I usually hear is, “When can we stop doing this?” or “Why does this keep happening?”, not, “I don’t understand why shouldn’t we just intubate everybody who comes in critically ill”.

Alex: So are there any studies of barriers to implementation of palliative care in the emergency department?

David: Actually, with the American Academy of Emergency Medicine, we did an internal assessment of our 3,000 or so emergency physicians. What we found was the greatest cited barrier for implementation of palliative care in the ED was a lack of time on shift. Almost half of respondents said that was a significant barrier. But, their second cited issue was, for about a third of respondents said that it was just absence of coordination with their palliative care service that prevented them from better delivering palliative care in ED. Interestingly, lack of interest was not on the list. Less than 3% of people said that they weren’t interested in implementing palliative care or incorporating that into their practice.

It was more of a question of, how do we get from here to there? How do we actually do this given how busy we are in the environment we work in?

Eric: Well that’s a hopeful result right there.

David: I think so. I think times are changing.

Alex: Now, when you say lack of time on shift, do you mean that they felt like, “I want to do more in this area, but I just don’t have time to have that extensive goals of care conversation with this patient, given the time pressures of the shift work and the other patients that I need to see”?

David: That’s definitely part of it. I think there’s this perception that maybe that to have an effective goals of care conversation, you need to talk for a long, long time. But actually, what I’ve seen play out in my own practice, as well as observing some of my colleagues and mentors, it’s really not the amount of time you spend having the goals of care conversation, it’s how you do it, how much time you’ve been listening, what questions you ask. We know this, but as a real paradigm shift for the more telling or talking based conversation that often happen in the ED.

Eric: That’s great. So, we just had a podcast, which we published last week, with Kei Ouchi, on prognosis after emergency department intubation. If I remember the data right, a third of older adults, after emergency department intubation, did not survive the hospitalization, and 50% of those greater than the age of 90 years of age did not survive hospitalization. These are pretty shocking statistics for intubation in the emergency room for older adults.

David: It’s unfortunately a daily occurrence I think in every ED across the country. I’m thankful for our major academic institutions to kind of put numbers around this and look into it, but that sense of maybe prolonging death or not returning people to the life they previously had is definitely shared by emergency providers.

Alex: So, let’s talk about the integration of palliative care in the emergency department. There are kinda two angles to this. One is training of emergency medicine providers in palliative medicine skills, so, primary palliative care. The other angle is secondary palliative care in the emergency department, or consultants coming in, who are specialized in palliative care, to the emergency department. We’ve touched a little bit on the first. Is there more that you want to say about training emergency medicine providers in palliative medicine, or should we move to the second?

David: One other thing I would say is, if an ED provider tells you that they’re interested in learning more skills, there are different avenues through which they may enhance their own practice, beyond doing a fellowship. There is workshops like EPEC-EM, which is a two-day course. There’s EM Talk, which is a derivative of Vital Talk, to learn more about communication, strategies. So, there’s ways for emergency providers who are wanting to improve their own skillset without transitioning clinical environments.

Eric: And as far as specialty teams are concerned, so probably the most basic model is, I have an inpatient consult team. I get called by the ED. I go down there and see a patient. Rarely happens, but it does. Are there other models … You were just at AAHPM, right?

David: Mm-hmm sure was.

Eric: At the annual meeting you probably heard some cool models. Are there are other models besides that model that we should be looking into?

David: Yeah. We actually presented on this at AAHPM. I mean, the sky’s the limit. It depends on what amount of resources you’re willing to commit to that acute care experience for patients. It can range from patients who are actively dying and being able to structure a better experience for them in the ED, maybe circumventing an emission, direct to hospice discharges. It can also be a pipeline to your inpatient palliative care unit, your outpatient clinics, earlier consults on your consult service. And so, it really depends on what the goals, whatever initiative you want to design are and whether you have the bandwidth to create infrastructure around that.

Eric: Can you give me a couple of concrete examples of what some of these pipelines could look like?

David: So generally, I think for most palliative care programs, you’re starting off with a consult service, it tends to be the lowest hanging fruit. And having a early identification of patients process, a trigger system, is one way in which you can really engage specialty level palliative care earlier. That can involve EMR triggers. It can involve using different criteria like the P-CaRES one that was published in 2015 or some derivation that maybe is simpler, which is what we’re using down in Scripps Health right now. The goal of that would be, you can design that for high specificity or high sensitivity just to create more consults for your service or, I know many palliative docs are nervous that opening that box might result in them being at work 24 hours a day and sleeping in the sleeping bag in their office, you can decide with more specificity such that you’re really just trying to move your time to consult much sooner in the patient’s course.

Eric: So what do you actually do at Scripps?

David: We’re using a very streamlined set of criteria to trigger inpatient consults.

Eric: Which include?

David: One, the presence of an incurable, serious illness. Two, the patient is now mainly limited to being in a bed or chair. So, about a PPS of 50%. There’s something to start the conversation. This disease has actually changed their life.

Eric: Are these and-?

David: Yes and criteria. And number three would be, if the emergency physician thinks it would not be a surprise if the patient dies during the hospitalization.

Eric: The surprise question.

David: The good old surprise question, which, as you guys know, is not a bad use. It’s probably on par with quantitative models. But it’s probably the most sustainable to use in the ED, because it’s simple, and it’s effective, and it’s simple.

Alex: And you modified it to be would not be surprised if they died during this hospitalization.

David: Right.

Alex: Which is a much shorter timeframe from the original surprise question.

David: Right.

Eric: So it sounds like maybe more high specificity. You don’t want to unleash the floodgates at Scripps.

David: Right, because for us, I think our consult service is fairly mature. We’re probably operating at our optimal bandwidth. And really, what we’re wanting to do is just get the patients earlier, especially our patients who skip the ICU, who are already, you know, DNR/DNI, but perhaps end up getting a series of interventions or diagnostics that don’t really make sense or don’t make an actionable difference.

Eric: Any tips for collaborating with the emergency department, like how you did it, or things that other palliative care consult services could model?

David: Well it takes a village. I mean, the criteria is simple. As you saw, a lot of it is making sure that everybody is on board with that. So, making sure you have good buy-in from your ED. You got to have a champion in your ED. You have to have good representation in your hospitals and ICU groups. It’s always helpful to have someone from administration who backs this. For us at Scripps, we’re leaning in towards more of an ACO model of care. So, there’s system-wide interest in building these collaborations. Some places maybe are still more in the fee-for-service world and don’t necessarily want to do a lot of this, so it’s about figuring out how do you make this kind of a win-win-win for everybody involved.

Alex: I want to go back and underscore one of the points that you raised about sleeping in the office in a sleeping bag, which cannot be emphasized enough. As a practicing palliative care consultant, I think it’s great to collaborate with the emergency department during business hours.

Eric: If only patients followed these rules, don’t come in after hours.

Alex: This is a real issue, and this has been identified from the earliest studies in this area. The sickest patients, the most complex patients come in often in the middle of the night and on the weekends.

How can we restructure or provide the best care for those patients, including palliative care in the emergency department, given this constraints of most palliative care services and the real need to not overwhelm services who are often already working a fine line of work-life balance, and the real needs to have time away from work, for people whose schedules are pretty set and don’t have that shift work mentality of emergency medicine work. Any thoughts?

David: Yeah, I think that’s a shared fear. When I talked to a lot of other palliative care docs about engaging the ED, that’s one of the first things that comes up, which is, “I want to do the right thing for patients, but these are the hours I’m at work, and I’m not going to be available 24/7 like the ED is”. I’ll start by saying right off the bat that I don’t think the ED expects palliative care to be available 24/7. I mean, if your service is already 24/7, wonderful, but if not, I think it’s about creating kind of a culture of expectations around that. Many services that the emergency physician will call or interact with won’t be available all the time.

So, for us, for instance, we are seven days a week, but we’re not night coverage. And so, they will call our consult number and leave us a voicemail. We have assured them that we’ll see the patient within 24 hours of their call that they don’t need to expect a call back from us and wait for that, because that is one of the cardinal sins in the ED, to make one of their docs wait. But at the same time, if they have something of urgence during the daytime, we will prioritize that consult, and we’ll come as soon as we are reasonably able to, and that has worked well. I think being an emergency physician myself, as long as that communication is clear and I know what to expect, so I don’t ask for more than that, I’m not disappointed by not getting more than that, then that is acceptable.

And in the same lines, there’s certain lingo differences in emergency medicine that’s important to know. For instance, if a palliative care doc gets called for a consult and says, “I’ll be right there after my family meeting. I’m stepping into a family meeting. I’ll head there right after.” It’s important to clarify that that family meeting is not a five-minute meeting, that that might be an hour north of that, because that may be something that the emergency docs aren’t familiar with. Goals of care conversation in ED can happen in five minutes. So, that notion may be a little bit foreign.

Eric: Other lingo issues? So we got one really important pearl, which is don’t let them hanging on the consult request. Another is …?

David: I have a couple more. One would be to help your ED colleagues out, help clarify the consult question right off the bat. So, you might get a call saying, “This is a 90 year-old guy. He’s pretty demented. He looks like he’s got a really bad pneumonia. I think he’d really needs palliative care.” So, what does that specifically mean? Is this an emergent goals of care clarification? Is there some other advanced directive we should review? Or maybe he’s not that bad and you just think he maybe will survive this and at the hospice. Like, what does, “He needs palliative care,” mean? So unpacking that a little bit on the phone and kind of crystallizing what their ask is, because they may not necessarily know specifically we’re in the dimensions of palliative care, the need is, but they know that they don’t want to give him like the full resuscitative course. The third thing I would say is, as much as possible, when presenting recommendations on the phone, use if-then statements. So, for instance, if you’re called for a refractory malignant bone pain, try one milligram of this, and if it doesn’t work in 30 minutes, give another dose or double the dose and if that works, he can go home with this altered regimen.

Eric: So almost like a flow diagram of what to do.

David: Right, and then, you know, AB statements, as close-ended as possible as it can be for the ED doc. They would appreciate that, because the emergency physician wants to understand a little bit of everything but don’t have the ability to go really deep in some of these fields. And so, while we in palliative care dwell a lot in the uncertainty of various patient situations, as simple and closed-ended as it can be in our recommendations to the ED, the more helpful that would be.

Alex: That’s great, because among many emergency medicine treatment algorithms are sort of protocolized and like an algorithm of, “If this, then that. If this, then that,” so that the recommendations should follow that format to be optimally received.

David: Right. One of the things that I think is also very frustrating for emergency physicians is, when the disposition is unclear. So, the patient maybe who is pending discharge for hospice or maybe it’s going to go to hospice but needs a brief time in observation and control their symptoms, that uncertainty around who manages the patient or where they’re supposed to go from the ED, can be really challenging. While doing the right thing for the patient, giving the best care possible is always the goal, two pressures that the ED faces is one, med legal as we talked about. And the other is patient flow and disposition being the most important metric that a lot of emergency physicians and departments are held accountable to.

Alex: I’ve heard of some patients being discharged from the emergency department or from OBS to hospice, enrolling in hospice directly. Is that something that you have experience with in the Scripps health system?

David: Yeah, and actually, there are patients that directly discharged to hospice from Scripps. One organization that does it very well is Kaiser, and you can imagine more of it in a vertically integrated model. They’re really able to ensure that those patients get good follow-up immediately. For that to happen, at any ED around the country, there has to be a good case management and social work presence in the ED, to make sure all those lines are connected, all the DME that they have, they need, insurance issues. What’s often challenging for the hospice discharge is, as we talked about just now, the patient who needs to stay just a little bit to get their symptoms controlled, and what that temporary admission observation stay in the ED or through the internal medicine service would look like, the service agreements around who manages that patient.

Eric: I’m also wondering if we can go back to different models of integrating palliative care. Are there other models that you’ve seen or you’ve talked about at the annual meeting that are more integrated too, where palliative care is in that department, not just the consulting service?

David: Yeah. Over at St. Joe’s in New Jersey, they have what’s called the LMSA program, where they have I think a palliative care nurse who actually basically trolls around the ED for patients and looks for patients at where they may have an active intervention on for symptom control, also for patients who are actively dying. There’s nothing that pleases an ED doc more than saying, “Hey, I’m here, and I can take over the care of the patient”. And so, they are actually physically embedded into the ED. For some ED docs who’ve done palliative care training, they will, depending on what health system they work for, if they can fund that position, they specifically sit in the ED during daytime hours, and they actively solicit those patients to clarify, to do things like clarifying goals of care, addressing family discord, hospice discharges, if those are possible. There was one ED, I think it was … I can’t remember, but they got a pilot study to fund a palliative care nurse to be in the ED five days a week, just daytime hours. They saw a profound impact on just the amount of patient touches they had, and they were very valued by the EDs having that service, to provide that service.

Alex: That’s great. We’ll provide links to these studies in the post that’s attached to this podcast.

Eric: Okay. So maybe to end this podcast for our listeners, can you tell us maybe three very practical things, besides listening to GeriPal podcasts, that palliative care services could do to better integrate with their emergency department colleagues?

David: I think a good starting point, the first thing you should probably do is take a look inward at yourself, at your own service. What is your hope of this project? You know, engaging the ED. Are you trying to treat more consults? Are you trying to funnel patients into your clinics? What do you have the bandwidth to actually handle? And then you should design your initiative to create the impact that you want to meet those goals. There’s an almost innumerable number of things you could do either through primary palliative care education or secondary palliative care utilization, but you got to know what you’re driving at first, otherwise it might make your own team frustrated.

Once you have a sense of what that is, I think the next most important thing to do is identify an ED champion, someone who has called you before, who is somewhat understanding of palliative care needs of the patient and understands a bit of what palliative care has to offer, because you’ll need an insider voice to really be able to champion any sort of culture change or a new project. And then once you have that, you know what you want, and you know somebody in the ED who will help you champion that, I think they should start them with a needs assessment of the ED. What is their understanding of the palliative care service? What do they think would be most useful to them? And then build from there.

It would be probably ineffective to try to take something that’s worked somewhere else and copy it, ceteris paribus to your own hospital. It’s much better to understand what’s been out there, the realm of possibility, but then figure out what you guys specifically need where you are and then to target your resources and program development from there on.

Eric: Wonderful. I want to thank you for joining us on this podcast.

Alex: Thank you, David.

David: It’s been fun to be here. Thanks guys.

Eric: Shall we end with a little bit more of Take Me Home, with edited lyrics by Alex?

Alex: Let’s see if we can do a better job.

David: Are we doing our version or the right version?

Alex: We’ll do the right version this time. We’re going to start from the top.

David: All right. [Singing]

Eric: Thanks for everybody who listened to our GeriPal podcast. We look forward to having you on next week with us. Have a good day.