American College of Emergency Physicians

View all recommendations from this society

October 14, 2013

Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

Palliative care is medical care that provides comfort and relief of symptoms for patients who have chronic and/or incurable diseases. Hospice care is palliative care for those patients in the final few months of life. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can benefit select patients resulting in both improved quality and quantity of life.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1–5: The American College of Emergency Physicians (ACEP) developed five Choosing Wisely® recommendations through a multi-step process that included input from ACEP members, an expert panel of emergency physicians and the ACEP Board of Directors. In 2012, ACEP appointed a task force to address cost effective emergency care. The Cost Effective Care Task Force conducted a survey that was open to all ACEP members asking for strategies to reduce cost and improve value in emergency medicine. The task force received over 200 individual suggestions, which were grouped into a set of strategies. A technical expert panel, including representatives from all aspects of emergency medicine practice, reviewed and prioritized the recommendations using a modified Delphi technique. The panel prioritized the strategies using multiple rounds of voting based on contribution to cost reduction, benefit to patients and actionability by emergency physicians. A literature review including data on cost was assembled for the highest-rated strategies. Strategies were further refined and a final list of strategies that received majority support of the panelists was created. Five of these were ultimately selected by the Board of Directors to be included in Choosing Wisely®.

6–10: The entire ACEP membership (30,000+) was surveyed and given an opportunity to provide input on what in their view would be cost effective and improve the quality of patient care. A Delphi panel of emergency physicians was convened and the list was winnowed using the Delphi process to the top twelve. To be included in the top twelve, there must be research to demonstrate cost effectiveness and improvement of patient care if implemented with reason, caution and explanation to the patient. Also of importance was the consideration that the recommendations would be or are also in concert with some of the other specialties participating in the Choosing Wisely® campaign.

ACEP’s disclosure and conflict of interest policy can be found at www.acep.org.

Sources

DeVader TE, DeVader SR, Jeanmonod R. Reducing cost at the end of life by initiating transfer to inpatient hospice in the emergency department. Ann Emerg Med. 2012;60(4s):S73.

Kenen J. We can’t save you: how to tell emergency room patients that they’re dying. Slate [Internet]. 2010 Aug 4 [cited 2013 Sep 4]. http://www.slate.com/id/2262769/.

Quest TE, Marco CA, Derse AR. Hospice and palliative medicine: new subspecialty, new opportunities. Ann Emerg Med. 2009;54:94–102.

Smith AK, McCarthy E, Weber E, Cenzer IS, Boscardin J, Fisher J, Covinsky K. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff. 2012 Jun31:1277–85.