A “palliative pause”―end-of-life crises deserve priority in the ER or clinic

The Inquiry Committee recently concluded an investigation of a profoundly sad complaint alleging over-treatment of a terminally ill young adult, contrary to her expressed wishes, in the emergency department and palliative care ward of a major BC hospital. With the dedication of her parents and expertise of community and BC Cancer Agency palliative care teams, the patient had received exemplary care at home, focused on aggressive symptom management and informed by constant consultation with patient and family. Unfortunately, near the very end of her life, the patient suffered a significant fall. A fractured femur was suspected and an ambulance was called.

In their complaint submissions, the bereaved parents poignantly described a jarring cultural shift at the emergency room door. At home, every intervention was carefully considered and administered only with the explicit consent of the patient. At the hospital, assessments felt algorithmic and rushed, and tests and interventions (blood work, ECG, catheterization and IV resuscitation) were administered seemingly without adequately considering the wishes of the patient, who died on the second day in hospital.

The physicians responded to the complaint by describing the palliative intent of their interventions and impressions formed at the time that the care was accepted and appreciated. There was reportedly no overt objection or resistance from patient or family and, from a medical perspective, the care was considered supportive.

With the benefit of hindsight, it would have been better for all concerned if the otherwise-superb community palliative care in this instance had included a well-documented crisis plan, with advance direction from the patient, and telephone availability of a nurse or physician familiar with the circumstances. However, advance planning can never anticipate every eventuality. Patients at the end of their lives and their families are owed a supportive, unhurried consent process at every stage, even in a crisis.

Based on its careful review, the Inquiry Committee concluded that the actions of the physicians were reasonable, given the limited supports available to them at the time. At that point, the committee considered observations offered by a member of the Health Professions Review Board (HPRB) in her review of this case. Noting that “the complainants’ determination to affect change and the deep disappointment that their daughter’s request for end of life care was not realized,” she suggested that College standards for all physicians for palliative care patients could prevent events like these. 

The committee was doubtful that a standard was the best tool. Rather, if surgical and baby pauses improve patient safety, a similar approach could be applied when palliative crises present to ERs, GPs’ offices or walk-in clinics to improve the quality of communication, consent, and care for vulnerable patients and their families. The Inquiry Committee recommended that ER, primary care and palliative care providers consider collaborating on the development of protocols and checklists to operationalize a “palliative pause” or “code palliative,” where routines are set aside and a designated team member sits down with the patient and family to make sure everyone involved in the care of that patient knows exactly what is wanted. Standard documentation, including facilitated contact with community caregivers would be part of the process. It need not tie up a lot of resources. It would simply mean that, like hemorrhagic shock, chest pain, and respiratory distress, a system is in place to ensure that such patients receive prompt and consistent attention.

The College does not have the authority to direct or be prescriptive about improvements to the system of care. It does have an obligation to be supportive. Physicians who have a leadership role in emergency, primary, or palliative care are invited to contact the College to discuss this issue with a member of the registrar staff.