Emergency medicine and end-of-life care: A holistic approach

Emergency rooms excel at resuscitating, stabilizing, and saving lives. This care is essential for many individuals, but for patients who are terminally ill or nearing the end of life, aggressive interventions can be traumatic and misaligned with their wishes.

Dr. True McMahan, an emergency physician in California, has often felt this tension. “I’d been in emergency medicine for about 10 or 12 years when I realized that some of the things I was doing were aggressive and futile and even harmful,” she reflects. 

Over half of older adults will visit the emergency department (ED) in the last month of their lives. And most say they value the quality of their life over simply extending it, yet emergency care often defaults to aggressive treatment.

Additionally, a recent study published in JAMA Internal Medicine found that for older adults, every hour spent in an ED can increase their risk of immobility and delirium — a sudden change in thinking, attention, and awareness that typically leads to confusion and other symptoms. The study also found that time spent in EDs is on the rise.

A more holistic approach: Integrating palliative care

For these reasons, it is essential that emergency providers are equipped to provide a more diverse range of care, including palliative care and assistance with advance care planning. These services help patients clarify what matters most and ensure that treatment aligns with their goals.

Our work with emergency medicine practitioners helps make that happen and improves the end-of-life experience for people across the country.

We bring together professionals — including physicians, social workers, chaplains, and more — to share best practices and research with one another. By uniting emergency and palliative care, providers can create space for meaningful conversations about care goals with their patients and offer appropriate treatments in response. This work helps shift emergency medicine away from a “one-size-fits-all” model to a more patient-directed process. And the results speak for themselves.

Creating change for patients and providers

Integrating palliative medicine into emergency settings has been shown to improve outcomes, increase satisfaction, and reduce expenses for individuals and providers alike.

Driven to better serve her patients, Dr. McMahan pursued additional training in palliative and hospice care. She now helps teach fellow emergency physicians how to identify patients who might benefit from palliative care or hospice and how to initiate honest, compassionate conversations about end-of-life options.

Dr. McMahan admits those conversations often aren’t easy. She recalls seeing a patient in her 80s who had been admitted to the ED, discharged, and then admitted again a few days later. The patient and her daughter both looked sad and tired.

“I told the daughter, ‘The hardest thing I’m going to say to you is, I believe your mother’s dying.’ She broke into tears and said, ‘I think you’re right.’ I told her, ‘Now that we know this, we have options. We can be aggressive in controlling her symptoms and making her feel better while she is going through the dying process, or we can be aggressive and use medications and painful procedures to keep her alive a little bit longer. But the end is near.’ I can still remember where we were in the ED — Room 11. It made such an impression, the daughter’s sense of relief, and the patient was happy with the decision.”

While those words were hard for her to say, seeing a positive outcome made all the difference. Based on her experience, Dr. McMahan believes that “every single specialty should know a little bit about palliative care, but emergency medicine in particular… Education is key. Once you get enough provider education, then better decisions can be made.”

As patients, caregivers, or healthcare proxies, we can each make a difference, too. If you are heading to the ED — or accompanying someone who is — bring copies of important documents like advance directives and POLST or MOLST forms. Don’t hesitate to ask clarifying questions to ensure you understand different treatment options and expected outcomes. You have a right to speak up and advocate for the type of care you do, and don’t, want.