A Case for Education in Palliative and End‐of‐life Care in Emergency Medicine

I n this issue of Academic Emergency Medicine, a resident author vividly describes the challenging case of a conscious patient who presents with an acute, catastrophic, nonsurvivable illness. This portfolio submission recounts an unenviable task that, while uncommon, is a shared experience of most emergency physicians (EPs): providing a prognosis of impending death to an unsuspecting patient. Communicating such horrific information is a high-stakes event—physicians never have a second chance to deliver that bad news differently or better. I commend the author for doing an excellent job when faced with this duty for this first time. Clearly the resident exhibited empathy and professional competence that will be remembered by the patient’s family members for years to come. Although the resident performed well in this case, the reflection highlights the need to improve the training of EPs in the domains of palliative and end-of-life care. The author considers, ‘‘how many times I had done scripted bad news notification . . . [but] this situation was so drastically different . . . death had not occurred but was certain and near.’’ The implication is that this clinical case was uncharted territory for which the resident had not been adequately prepared. What if the case did not result in such a rewarding, positive patient interaction? What if the resident had performed poorly? How would such an outcome affect the remainder of the resident’s training and future care in similar situations? Although a negative clinical experience can at times result in provider growth and maturation, a high-stakes error can be paralyzing for some residents. Training in palliative medicine and end-of-life care augments the natural humanism of a provider with deliberate, formal education in topics germane to the care of patients with life-threatening or severe advanced illness. Palliative medicine seeks to alleviate suffering and promote quality of life. Principles of palliative medicine can be applied in the emergency department (ED) to address the various forms of physical, psychological, social, and spiritual suffering associated with terminal disease. Primary skills of palliative care for emergency providers include treatment of pain and other symptoms common at the end of life, delivery of bad news, and assistance to patients and family members trying to cope with urgent and difficult treatment decisions. Four core cognitive domains of palliative medicine are evident in the case recounted in the resident portfolio: 1) death trajectories, 2) prognostication, 3) breaking bad news, and 4) goals of care.