History of Palliative Care

What is Palliative Care and How is it Different From Hospice?

Palliative care aims to improve quality of life for seriously ill patients by providing pain and symptom relief, as well as spiritual and psychological support. Palliative care can occur at the same time as all other treatments for the patient's illness and is not the same as hospice. They share the same care goals, but hospice is specifically for patients in the last months of life whereas palliative care is appropriate for those in any stage of serious illness and can be provided alongside disease-directed treatments.

Why Emergency Medicine?

Patients with serious illness often visit the emergency department (ED) as their disease progresses and symptom burden or complications occur. Ideally, patients should have good primary care that manages their chronic illness and goals of care. However, due to our fragmented health care delivery system, the ED is often the default site of "primary care" for seriously ill patients. This gives emergency physicians an opportunity to provide better care for our patients in the ED by addressing their palliative needs.

The History of Palliative Care within Emergency Medicine

In 2006, hospice and palliative medicine (HPM) became an officially recognized subspecialty where emergency medicine (EM) physicians can obtain board certification. Currently, there are about 211 dual-board-certified physicians (EM and HPM) with likely more EM physicians now only HPM certified. There are a growing number of EM-palliative care training, education, research, and ED-embedded models. EM-HPM is now an established pathway for EM physicians seeking an academic career, dual clinical practice, or transition to HPM career. In 2021, "Best Practice Guidelines for Primary Palliative Care in the Emergency Department" was published and outlined the cornerstones of EM-HPM care in screening and needs assessment, symptom management, consultations, and transitions of care. Nationally, we continue to grow as a subspecialty within EM with active interest groups at the Society for Academic Emergency Medicine (SAEM), the American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and the American Academy of Hospice and Palliative Medicine (AAHPM) filled with a core group of active members.

The Future of Palliative Care within Emergency Medicine

The EM practice paradigm for the seriously ill continues to shift to incorporate more palliative care practices through knowledge, recognition, and application/integration. Through this, primary palliative care (provided by EM physicians) and secondary palliative care (provided by those with specialized HPM expertise) in EM expands as shown below.

Figure Source: George N, Bowman J, Aaronson E, Ouchi K. Past, Present, and Future of Palliative Care in Emergency Medicine in the USA. Acute Med Surg. 2020 Mar 18;7(1):e497.

Careers in EM-HPM

Unlike some other fellowships, HPM fellowship is meant to train you as an independent HPM physician who can practice completely independent from emergency medicine. That being said, HPM-EM trained physicians have a variety of options on how to split their time between the two specialties depending on career goals, desired clinical hours, and salary compensation

Most EM-HPM dual-trained physicians work in major academic institutions where they split their clinical time between inpatient palliative care and ED shifts in addition to teaching palliative care and/or research. Others practice only clinical EM while being an advocate for palliative care in their department or serve on the ethics committee for their hospital system. Others transition to HPM completely. Regardless of your path, you are an asset as an EM-HPM physician. You can lead in your department in medical education for palliative care, start an embedded palliative care program in the ED, and collaborate on EM-HPM projects or research.