Palliative care provision in the emergency department: Barriers reported by emergency physicians

Background: There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated. Objective: To elicit the ED physicians' perceived barriers to provision of PC in the ED. Methods: ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers). Results: Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation. Conclusion: We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.