Geriatrics/concepts
Hospice and Palliative Medicine: New Subspecialty, New Opportunities

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Palliative care is the physical, psychological, social, and spiritual care provided to patients from diagnosis to death or resolution of a life-threatening illness. Hospice care is a comprehensive program of care that is appropriate when patients with chronic, progressive, and eventually fatal illness are determined to have a prognosis of 6 months or fewer. Hospice and palliative medicine has now been recognized by the American Board of Medical Subspecialties as a field with a unique body of knowledge and practice. With 9 other specialty boards, the American Board of Emergency Medicine has cosponsored hospice and palliative medicine as an official subspecialty. As a result, board-certified emergency physicians may now pursue certification in hospice and palliative medicine through either fellowship training or, for a limited time, completing practice track requirements, followed by a written examination in the subspecialty.

As the practice of palliative medicine grows in hospitals, emergency physicians can develop a core of generalist palliative medicine skills for use with adults and children. These would include assessing and communicating prognoses, managing the relief of pain and other distressing symptoms, helping articulate goals of patient care, understanding ethical and legal requirements; and ensuring the provision of culturally appropriate spiritual care in the last hours of living. Front-line emergency physicians possessing these basic palliative medicine skills will be able to work collaboratively with subspecialty physicians who are dually certified in emergency medicine and hospice and palliative medicine. Together, generalist and specialist emergency physicians can advance research, education, and policy in this new field to reach the common goals of high-quality, efficient, evidence-based palliative care in the emergency department.

Section snippets

Hospice and Palliative Medicine: Overview

Hospice and palliative medicine, a newly designated subspecialty of the American Board of Medical Subspecialties (ABMS), is an advanced-level practice that focuses on the total care of patients with life-threatening illness, whether curable or terminal.1 Although there is a recognition that palliative care is provided by all clinicians, conferring subspecialty status by ABMS gives palliative medicine a well-defined field of practice with a distinct base of medical science on which graduate

Generalist or Basic Palliative Care in the ED

At the present time, the emergency clinician faces clinical dilemmas in palliative medicine without the benefit of either having mastered a set of educational competencies in palliative care or of having a palliative medicine subspecialist at his or her side. Educators in emergency medicine have not yet comprehensively defined or embraced a core palliative medicine skill set for emergency providers. Although emergency medicine develops a core curriculum in palliative medicine, the National

Clinical Case

H.M. is a 68-year-old man who presents with stage IV non–small cell lung cancer that has been refractory to several lines of chemotherapy and now has severe uncontrolled pain in his right chest wall, a known site of bony invasion of metastases. The patient spends most of the day in bed and is eating and drinking very little. He is taking morphine continuous release of 60 mg every 12 hours and rates his pain in his left chest wall as a 9 of 10. His son accompanies him and says he has become

Clinical Case Conclusion

The case of H.M. can now be appropriately managed with the key precepts listed above. Using the cancer trajectory for the patient and observing that the patient is now bed bound, the emergency physician realizes that the patient now has just weeks to months to live. A candid discussion with his oncologist confirms this, and the oncologist reluctantly admits to the emergency physician that, given the patient's functional or performance status, he has nothing more to offer him in the way of

A New Opportunity for Emergency Physicians: The Subspecialty Practice of Palliative Medicine

Emergency clinicians will struggle during the next decade on the optimal skill set and model to provide the best palliative care in the ED setting.103 Currently, emergency physicians with a strong desire to deepen their expertise in palliative care may wish to pursue a career in subspecialty palliative medicine practice. Requisite to successful practice is a willingness to accept death as a normal part of life and move beyond the now obsolete belief that death means failure. Embracing the

Emergency Physicians' Pathways to Palliative Medicine Subspecialty Board Certification

Before the recognition by the American Board of Medical Specialties, the non-ABMS American Board of Palliative Medicine specified criteria for board certification and administered the qualifying examination. With the approval of subspecialty status by the ABMS, all currently certified hospice and palliative medicine diplomates will be eligible to take the new Hospice and Palliative Medicine Certification examination. It is estimated that there are more than 1,500 physicians in the United

Conclusion

Emergency clinicians provide palliative care to patients in their daily practice and have done so since the inception of the specialty. Building on this component of emergency practice, the new subspecialty of palliative medicine has opened to emergency physicians. Whether one pursues specialization or not, all emergency clinicians can use the growing body of knowledge of palliative medicine in their bedside ED practice. Education of current core faculty responsible for postgraduate training is

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    Supervising editors: Robert J. Zalenski, MD, MA; Michael L. Callaham, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Quest is funded as a co-investigator by the National Cancer Institute (5 R25 CA116472) for work on the EPEC-Emergency Medicine Project.

    Publication date: Available online January 29, 2009.

    Reprints not available from the authors.

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