Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic

Emily Loving Aaronson; Bethany-Rose Daubman; Laura Petrillo; Jason Bowman; Kei Ouchi; Alexa Gips; Lara Traeger; Vicki Jackson; Corita Grudzen; Christine Seel Ritchie

doi:10.1016/j.jpainsymman.2020.10.035

Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic

J Pain Symptom Manage. 2021 Jul;62(1):117-124. doi: 10.1016/j.jpainsymman.2020.10.035. Epub 2020 Nov 6.

Authors

Affiliations

¹ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA. Electronic address: emily.aaronson@mgh.harvard.edu.
² Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁵ Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Palliative Care Service, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
⁶ Department of Emergency Medicine, NYU Langone Health/Bellevue Hospital Center, NYU Grossman School of Medicine, New York, USA.
⁷ Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.

Abstract

Context: Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs.

Objectives: To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic.

Methods: For this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations.

Results: Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories.

Conclusion: Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.

Keywords: COVID; Emergency medicine; end-of-life care; goals of care; palliative care; palliative medicine; patient care planning.

MeSH terms

COVID-19*
Emergency Service, Hospital
Humans
Palliative Care
Pandemics*
SARS-CoV-2