Catholic Health World

Emergency room is gateway to palliative care at St. Joseph's

What should the role of modern medicine be when it can no longer cure or prolong life?

Dr. Mark Rosenberg has some very definite ideas. "The goal should be to help patients understand their disease and remain in control of their lives as much as possible," he says. "We should be working to improve quality of life through the relief of pain and non-pain symptoms while also providing emotional, social and spiritual support."

The philosophy Rosenberg espouses is the cornerstone of palliative care — medical care that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay or reverse the progression of disease itself. But the venue in which Rosenberg practices his beliefs — the emergency department of a large medical center — is unusual.

Because of Rosenberg's background and perspective as chairman of emergency medicine at St. Joseph's Regional Medical Center in Paterson, N.J., the hospital last January chose to base its palliative care program in its emergency department.

The base is appropriate, says Rosenberg, since many patients with terminal or chronic illnesses, such as cancer or organ failure, make frequent trips to the emergency department when they become very sick, often without realizing the trajectory of their disease.

"The emergency room is an important point of entry for the hospital," he says. "It's often the conduit to intensive care units and all kinds of aggressive treatments — resuscitations, ventilations, intubations and so on. But it is also a place where we can have a much different conversation about the progression of disease and what kind of comfort and choices are available outside the hospital when patients and families are facing difficult end-of-life decisions."

While it may be a cliché that doctors learn from their patients, Rosenberg claims that his experiences with several patients approaching the end of life convinced him that an emergency department-based palliative care unit was critically needed. The one at St. Joseph's includes a core team of physician, nurse and social worker, with the addition of other specialists when appropriate.

One case in particular, that of a 25-year-old businesswoman suffering from glioblastoma, a very aggressive brain tumor, illustrated to Rosenberg that when patients and their families are given the factual information they need, they can make the right choices to help them face end-stage disease with dignity. (To protect the privacy of the patient's family, Rosenberg identified the woman by her first name only.)

"Staci was diagnosed in September 2009, and underwent two brain surgeries and chemotherapy by the end of November. We had seen her several times in the ED due to complications she was experiencing," says Rosenberg. "After the second operation, her oncologist told her he was unable to remove all of the tumor and that she would die. He wanted her to stay in the hospital with hospice care."

Staci had other ideas, however. "She had a long bucket list — she wanted to package everything for her family before she died. Among other things, she wanted to sell her business, leave a trust fund for her nieces and buy them a kitten, and give her belongings to a women's shelter. She wanted to be home for Christmas, and she wanted to watch a Cleveland Cavaliers game with her dad," says Rosenberg.

"Because of the strategies we were able to put in place for Staci, she didn't spend the last 14 days of her life in the hospital. She was able to concentrate on what was possible and make a good ending to a great life. She died on Dec. 28, knowing she had made choices that allowed her to go in peace."

A few days later, St. Joseph's started up its emergency department-based palliative care program, called Life-Sustaining Management and Alternatives. Since then, there have been approximately 80 patients who have made use of the program — far more than the dozen or so the unit originally had projected to serve this year.

In an article coauthored by Rosenberg and published last month in Emergency Physicians Monthly, the writers say that emergency medical providers can be too rushed or too uncomfortable to talk to patients about end-of-life care, and this can be to the detriment of patients' well-being. The palliative care team at St. Joseph's tries to broach the subject when terminally ill patients become "frequent fliers" in the emergency room. "A bedside consult provides the patient and family with necessary information on their disease, prognosis and disease trajectory. It is designed to help patients live with their illness; and, at the extreme, helps patients and family deal with end-of-life issues earlier in the disease," Rosenberg and his coauthors wrote.

There are a variety of ways patients are identified as being in need of a palliative care consultation, Rosenberg explains. Some are identified by trained emergency department staffers when they come to the emergency room seeking relief from escalating symptoms. Others are referred by doctors in the community who are uncomfortable talking about the end of life with their patients. And sometimes patients and families request services on their own.

"So many patients seem grateful just to have enough information about their conditions to be able to make informed choices about treatment," says Rosenberg. "I remember in particular a 56-year-old man with lung cancer who came to the ED because he was afraid he was suffocating. No one had told him his disease was terminal. Once we provided symptomatic relief and discussed his prognosis, he said, 'I'm so glad you told me. I knew it, but no one was willing to talk to me.' We arranged resources that enabled him to stay at home, as he wished, and tape record messages to his young grandchildren before he died, three weeks later, surrounded by family."

End-of-life conversations naturally involve grief and bereavement, but Rosenberg says he and his staff feel strongly that it is essential to overcome any uneasiness in order to discuss the quality of whatever remaining life a patient may have.

"Medical professionals are not God; we have no right to predetermine what a patient's care should be. The most important times in life involve births, weddings and death. Whatever your destiny, you should have the chance to talk about it," he says.

Sr. Maryanne Campeotto, SC, vice president of mission at St. Joseph's Healthcare System, the hospital's parent, says, "We are here to provide a comprehensive spectrum of services designed to heal the minds, bodies and spirits of those in need, especially the poor and underserved. Patients who face progressive illness are among the most underserved, and this program is designed to provide highly specialized, compassionate care for them and for their families.

"This is a way to offer people options to approach the end of life in a way that makes sense to them, without aggressive treatment, but with comfort and control, whether they are in the hospital, in hospice or at home," she says.

Copyright © 2010 by the Catholic Health Association of the United States
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