Grand Rounds lecture presented at Palmetto Health Richland Emergency Medicine Residency Program / University of South Carolina School of Medicine, August 2016. Reviews the concept of Primary Palliative Care in the ED and the research efforts of The EPEC-EM Project: Education in Palliative and End-of-Life Care in Emergency Medicine.

1. Improving End-of-Life Care in
the Emergency Department
Michael A. Gisondi, MD
Associate Professor and Program Director
Medical Education Fellowship Director
Director, Feinberg Academy of Medical Educators
Northwestern University Feinberg School of Medicine
Presented to:
Palmetto Richland Emergency Medicine Residency
University of South Carolina School of Medicine
August 2016

2. In a 1996 Gallup survey,
over 90% of respondents
expressed a desire to die at home.

3. Instead, 80% of patients die
in hospitals or institutions.

4. Over 200,000 Americans die
in emergency departments
each year.

5. Can we meet patient preferences
at the time of death?

6. Objectives
Define ‘Primary Palliative Care’
Describe The EPEC-EM™ Project
Identify opportunities and strategies for
palliative care education and research in the
field of emergency medicine
6

7. Disclosures
(1) NIH Co-Investigator
“Palliative Care for Cancer Patients in
Emergency Wards” – 2007-2011
NCI - 1R25CA116472-01A1 (PI= Emanuel)
$1,298,000
(2) Faculty, The EPEC-EM™ Project
7

8. What is Palliative Care?

9. World Health Organization
“…the active total care of patients whose
disease is not responsive to curative
treatment.”
“Control of pain.. and of psychological, social
and spiritual problems is paramount.”
“The goal of palliative care is the achievement
of the best possible quality of life for patients
and their families.”
9

10. What is Palliative Care?
Palliative care actively addresses the physical,
spiritual, psychological, therapeutic, and social
needs of patients and families affected by
terminal illness, from the time of diagnosis of
a terminal illness to death, as well as
bereavement services for survivors.
10

11. Palliative Care Mandates
 Prevent and relieve suffering
 Affirm the dignity of the living
 Do not hasten or postpone death
 Offer a support system
 Utilize multi-disciplinary approach
11

12. Team Goals
 Pain and symptom management
 Information sharing
 Advanced care planning
 Psychosocial support
 Coordination of access to care
 Bereavement counseling
12

13. Active Comfort Care
Both patient and family centered
Improves the quality of life
Regards dying as a normal process
13

14. Patient Expectations
Patients and families expect that their
physician is competent in facilitating the dying
process
Until recently, end-of-life care was absent from
medical school and residency curricula
14

15. Death = Failure?
Many emergency providers see death as a failure
We are often uncomfortable with loss
We were not trained in the expected
pathophysiology of normal dying
15

16. Care Comes Too Late
We recognize dying very late
The average length of hospice care is 15 days
16

17. When should “End-of-Life”
care begin?
17
Palliative Care
Medicare
Hospice
Benefit
Disease Progression
Life Prolonging Care
Hospice Care
Life Prolonging
Care
Diagnosis Death

18. The EPEC-EM Project™

19. The EPEC-EM™ Project
The mission of The EPEC-EM™ Project is to
educate all emergency healthcare
professionals on the essential clinical
competencies of emergency palliative care
Education and research to drive performance
change
19

20. ‘Primary’ Palliative Care
The basic level of knowledge and skills that all
practitioners should have to relieve suffering
- Pain and symptom management
- Communication skills
- Ethical and responsible care
20

21. ‘Tertiary’ Palliative Care
Hospice and Palliative Medicine (HPM)
- Co-sponsored by ABEM
- Training and Practice Pathways
Unique clinical, research and service model of
emergency palliative medicine practice
21

22. Emergency Palliative Care
Identification of ED patients who will benefit
from pain and symptom management
ED providers committed to relief of suffering
through validated interventions
22

23. EPEC-EM™ Grant Timeline
Year 1: Define a body of knowledge
Year 2: Disseminate core content
Year 3: Create symptom assessments
Year 4: Test interventions
23

24. FY 1: Body of Knowledge
Goal: EPEC-EM™ Core Content
Developed by an expert, multi-disciplinary
advisory board
Adaptation of materials from original EPEC,
as well as ABHPM core content
24

25. The EPEC-EM Curriculum is produced by the EPECTM
Project with major funding provided by NCI.
Education in Palliative and End-of-life Care – Emergency Medicine
The
Project
EPEC-EM
TM

26. 26
Emergency Medicine and
Critical Care 2008; Oct;
4:46-8

27. 27

28. FY 1: EPEC-EM Curriculum
28
1. Death Trajectories
2. Rapid Assessments
3. Goals of Care
4. Advance Directives
5. Hospice
6. Communication Skills
7. Withdrawing Care
8. Witnessed Resuscitation
9. Death Disclosure
10. Symptom Management
11. Chronic Pain
12. Malignant Pain
13. Cancer Complications
14. Last Hours of Life

29. FY 2: Dissemination
 Goal: ‘Become an EPEC-EM Trainer’ Course
 2 day, train-the-trainer program
 400+ page course manual, teaching videos
 www.epec.net
29

30. Module 1:
Trajectories &
Prognoses
E
P
E
C
E
M
EPEC -EM
The TM
Project
Education in Palliative and End-of-life Care – Emergency Medicine

31. How do we die?

32. Global trajectories
• Terminal illness (e.g. cancer)
• Organ failure (e.g. CHF)
• Frailty (e.g. failure to thrive/SNF)
• Sudden death (e.g. trauma, V Fib)
• Lunney, Lynn et al. JAMA 2003.

33. Cancer
• Complications accelerate prognosis
Untreated Brain Mets
Treated Brain Mets
4-8 weeks
3-6 months
Malignant Hypercalcemia
(except breast ca and myeloma)
8 weeks
Malignant Effusion 8 weeks
Carcinomatous Meningitis 8-12 weeks

34. Prognosis drives goals and
interventions
Prognosis Days Weeks Months Years
Goals Comfort only Prioritize quality
of life over
longevity
Try
Interventions,
but stop if they
are not working
Full efforts to cure
Interventions Pain control
Family presence
by bedside
Refer to hospice
Treat for comfort
Refer to hospice
Attempt
resuscitation;
Stop if signs of
instability
persist after
reasonable
efforts
Full resuscitation
efforts; maximal
efforts to stabilize;
transfer to ICU

35. Video 1:
Trajectories &
Prognoses
E
P
E
C
E
M
EPEC -EM
The TM
Project
Education in Palliative and End-of-life Care – Emergency Medicine

36. FY 2: Outcome
12 EPEC EM conferences since 2007
Approximately 500 trainers
Over 25,000 end-users
Met NIH goal: 1 trainer at 50% of EM pgms.
36

37. FY 2: Secondary Outcome
EPEC-EM curriculum can be successfully
adapted to various types of learners and
instructional formats
Mini-EPEC
Asynchronous Learning
37

38. • EPEC EM adapted materials were effective
• Synchronous and asynchronous instructional
methods were similarly effective
38

39. 39

40. 40

41. 41

42. FY 3: Assess Symptoms
42
Goal: Develop a validated symptom
assessment tool for use in the ED

43. 43

44. FY 3 Outcome: SPEED tool
Validated, brief
Likert scale 0-10 with threshold values linked
to proposed interventions
SPEED-short (5 item version)
44

45. SPEED question
How much are you suffering from pain?
(threshold ≥ 4)
How much difficulty are you having getting
your care needs met at home? (threshold ≥ 3)
How much difficulty are you having with your
medications? (threshold ≥ 3)
How much are you suffering from feeling
overwhelmed? (threshold ≥ 5)
How much difficulty are you having getting
medical care that fits with your goals?
(threshold ≥ 3)

46. 46

47. 47

48. FY 4: Test Interventions
Goal: Develop meaningful interventions
linked to the symptom burden uncovered by
SPEED
Employ multi-disciplinary approach
48

49. 3. Clinical Care
Primary Assessment
EPEC-EM Protocol Flow Chart
Triage Patient presents to Emergency Department (ED)
How much are
you suffering
from pain?
Threshold = 4
2. First SPEED questions
0-10 point scale
1. Active cancer screen
How much
difficulty are you
having getting your
care needs met at
home?
Threshold = 3
How much
difficulty are you
having with your
medications?
Threshold = 3
How much are
you suffering from
feeling
overwhelmed?
Threshold = 5
How much
difficulty are you
having getting
medical care
that fits with
your goals?
Threshold = 3
If pt. scores above threshold values,
the Palliative Care Resource Nurse
is notified to interact with the ED
Power Plan. Power plan includes
specific interventions triggered by
SPEED categories above threshold.
(S)
Palliative Care
Consult
(S)
Social Work
Consult
(S)
Pharmacy Consult
(focused
medication
teaching)
(S)
Palliative Care
Consult
(S)
Social Work
Consult
(S)
Chaplaincy
Consult
(S)
Palliative Care
Consult
(M)
Pain Protocol
(M)
Secondary
Chronic Pain
Assessment
(M)
Secondary
Social Needs
Assessment
(M)
Secondary
Medication
Assessment
(M)
Secondary
Mental Health
Assessment
(M)
Encourage
verbalization
of goals
(S)
Palliative Care
Consult
(S)
Palliative Care
Consult
(M)
Secondary
Goals of Care
Assessment
(M)
Bedside
counseling
(M)
Goals of care
conversation
(M) = Mid-level provider
intervention (e.g.,
physician, nurse)
(S) = Sub-specialty
intervention
(e.g., social work,
chaplaincy, pharmacy,
patient liason)
Palliative Care Resource Nurse (PCRN) notified of patients scoring above threshold values on any SPEED category

50. SPEED Screening for Cancer Patients
How much are you suffering from pain?
0 1 2 3 4 5 6 7 8 9 10
How much difficulty are you having getting your care needs met at home (e.g.
bathing, dressing, and meals?)
0 1 2 3 4 5 6 7 8 9 10
How much difficulty are you having with your medications?
0 1 2 3 4 5 6 7 8 9 10
How much are you suffering from feeling overwhelmed?
0 1 2 3 4 5 6 7 8 9 10
How much difficulty are you having getting medical care that fits with your
goals?
0 1 2 3 4 5 6 7 8 9 10
Submit
Not at all A great deal
Ask the patient:
Threshold
values

51. Pain
Blue Text:
provider
decision
support
Pain Location:____________________
Pain Onset:______________________
Pain Scale Used
Numeric
Faces
FLACC
Behavioral/Physiological
Pain Score: 0-10 radio buttons
Pain managed to pts. satisfaction?
Yes
No
Pain Characteristics
None
Dull
Sharp
Aching
Burning
Stabbing
Pressure-like
Cramping
Crushing
Soreness
Constant
Intermittent
Radiating
Non-radiating
Generalized
Denies
Chest Pain
Incisional
Headache
Musculoskeletal
Other:________________
Pain Radiation:___________________
Secondary Pain Assessment
Behavioral Indicators
Grimacing
Moaning
Splinting
Tenseness
Restlessness
Agitation
Irritability
Shaking
Crying
Guarding
Physiologic Indicators
Increased respirations
Increased blood pressure
Increased heart rate
None
Other:_______________
Aggravating Factors
None
Breathing
Movement
Palpation
Other:_______________
Alleviating Factors
None
Assistive devices
Cold therapy
Deep breathing
Exercise
Immobilization
Massage
Moist heat
Repositioning
Other:_______________
Associated Symptoms
None
Nausea
Palpitations
Shortness of breath
Sweating
Vomiting
Other:______________
Side Effects from Pain Medications*
Constipation
Nausea/vomiting
Confusion
Drowsiness
Jerking movements
Other _______________
Daily Laxative Use*
Yes
No
Physician administers Pain Protocol (refer to Screenshot 3)
Physician/ midlevel requests palliative care consultation (as needed)
BLUE TEXT with
CHECKBOX:
Pain is uncontrolled,
Would you like to
order a palliative care
consult?
Yes – palliative care

53. Care Needs
At home, are you having difficulty…?
Using the toilet
Dressing yourself
Taking care of your hygiene
Moving around (mobility problems)
Managing medications
Preparing meals
Home-making
Getting around to places (transportation)
Are you having financial difficulty with…?
Utility bills (such as water, lights)
Groceries and food
Equipment (such as a wheelchair, harness)
Medications
Secondary Social Needs Assessment
Nurse requests social work consultation (as needed)
BLUE TEXT with
CHECKBOX:
Social needs are
unmanaged.
Would you like to
order a social work
and/ or palliative care
consult?
Yes – social work
Yes – palliative care
Physician/ midlevel provider requests palliative care consultation (as
needed)

54. Medications
Some questions about your
medications…
Do you feel like your
medications are ineffective?
Do you find the side effects
of your medications
burdensome?
Do you have trouble
physically taking your
medications?
Do you have trouble getting
your medications?
Do you understand how to
take your medications?
Do you feel uncomfortable
taking your medications?
Secondary Medication Assessment
Trouble getting medications
Cannot get insurance approval for medicine
Cannot get to pharmacy
Cannot pay for medications
Trouble taking medications
Form of medications (tablet, liquid, etc.)
Pill size
Difficulty swallowing
Taste of medication
Burdensome side effects
Constipation
Nausea/ vomiting
Drowsiness
Fatigue
Dizziness
Confusion
Flushing
Trouble understanding
Don’t understand regimen
Unfamiliar with regimen
Difficulty with literacy
Vision impairments
Hearing impairments
I
F
Y
E
S
.
.
.
S
H
O
W
D
R
O
P
D
O
W
N
T
A
B
L
E
(S)
Nurse requests pharmacist consultation for focused medication teaching
(as needed)
Physician/ midlevel provider requests palliative care consultation (as
needed)
Perceived inefficacy
No symptom relief
Partial symptom relief
Waning symptom relief
Discomfort
Uncomfortable with regimen
Fear of addiction
Fear of overdose
BLUE TEXT with
CHECKBOX:
Medication
communication needs
are unmanaged.
Would you like to order a
pharmacy and/ or
palliative care consult?
Yes – pharmacy
Yes – palliative care

55. Overwhelmed
Depression screen
Are you depressed?
Yes
No
Anxiety screen
Are you suffering from anxiety?
Yes
No
Overwhelmed Assessment
Do you have anyone I can call to be with you right now?
Yes – contact support directly
No
I could use support in the following areas:
Coping with Illness
Spirituality
Counseling
Support Groups
Getting support for caregiver(s)
Nurse provides bedside support and elicits information to inform potential
consult choice
CHECK BOX:
Provided bedside
counseling
If yes (depressed):
Suicidality Screen
Are you suicidal?
Yes
No
Normal procedures of hospital
to address suicidality
Nurse requests social work consultation (as needed)
BLUE TEXT with
CHECKBOX:
Patient is
overwhelmed.
Would you like to
order a social work,
chaplaincy, and/ or
palliative care consult?
Yes – social work
Yes – chaplaincy
Yes – palliative care
Physician/ midlevel provider requests palliative care consultation (as
needed)
Nurse requests chaplaincy consultation (as needed)

56. Goals of Care
Goals of Care Alignment Assessment
Physician/ Midlevel has goals of care conversation with patient and encourages verbalization with
primary care physician
Do you feel you are…?
Having trouble getting information that you need regarding your illness?
Receiving more medical interventions than you would like?
Having difficultly communicating your wishes to your medical providers?
In need of a healthcare proxy or advance directives?
BLUE TEXT with
CHECKBOX:
Goals of care need to
be discussed.
Would you like to
order a social work,
chaplaincy, and/ or
palliative care consult?
Yes – social work
Yes – chaplaincy
Yes – palliative care
Physician/ midlevel provider requests palliative care consultation (as needed)
Nurse requests chaplaincy consultation (as needed)
CHECK BOX:
Discussed goals of
care and encouraged
verbalization with
primary care physician

57.  Patient reassessed at end of stay
Post ED Visit
Admit / Discharge
Patient perspective of care:
A survey of patient centered
outcomes only for questions with
above threshold score at first
SPEED
How much are
you suffering
from pain?
How much
difficulty are
you having
getting your
care needs met
at home?
How much
difficulty are you
having with
communication
with your
medications?
How much are
you suffering
from feeling
overwhelmed?
How much difficulty
are you having
getting medical
care that fits with
your goals?
Second SPEED questions are
administered upon admission or
discharge only for questions above
threshold at first SPEED
4. Summary of care provided by ED
What could providers have done better to assess and respond
to...(your pain, your care needs, your difficulty with medications,
your feeling of being overwhelmed, your goals)?
Patient feedback opportunity:
Only for questions with above
threshold score at first SPEED
5. Admit/ Discharge survey
How much did providers do everything they could to help
with...(your pain, your care needs, your difficulty with medications,
your feeling of being overwhelmed, your goals)? NEVER,
SOMETIMES, USUALLY or ALWAYS
6. Follow-up survey
Patient follow-up survey conducted by
research assistant

58. 58

59. Future Considerations
59

60. Fiscal Imperatives
Emphasis on symptom assessments and
interventions with improved quality of life
outcomes and decreased hospitalization
Early ED palliative care has been shown to
decrease hospital stay and increase quality
60

61. Education and Research
Addition of core domains of palliative care to
the Model of Clinical Practice in EM
Define quality of life indicators, identify those
that can be addressed in ED
Focus on interventions, consultation
61

62. Summary
Palliative care is the active treatment of
physical symptoms and social needs
experienced by patients with terminal illness
EPEC-EM™ has defined core domains of
palliative care are pertinent to EM practice
There are numerous opportunities for new
knowledge and skills in palliative ED care
62

63. EPEC-EM 2016
Omni Chicago Hotel
September 8 & 9
www.epec.net
63