PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2013 COUNCIL MEETING.RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
40(13)
SUBMITTED BY:
District of Columbia Chapter
Aisha Liferidge, MD, MPH
Elizabeth Phillips, MD
SUBJECT:
Golden Care for Quality of Life
PURPOSE: Encourage palliative and hospice care consults in the ED; promote the use of the term “Golden Care”;
respect the dying patient’s needs and employ specific communication skills to assist the family and patient with
decision making at the end-of-life (EOL); support funding for research related to goal directed care in critically ill
patients, palliative, and hospice care in the emergency setting and better access to advance directives and DNAR
orders in the ED; focus advocacy initiative to raise awareness to the importance of access to and enforcement of
advance directives and/or DNAR orders and the significant amount of health care dollars that are spent on
unwanted admissions and invasive procedures at EOL; emergency physicians lead by example by completing
their own advance directives, discussing their wishes with family members, and designating a medical power of
attorney.
FISCAL IMPACT: Budgeted staff time and resources to address end-of-life issues.
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WHEREAS, Emergency departments frequently care for patients that are critically ill at the end of life
(EOL); and
WHEREAS, Death is more frequently related to chronic illnesses in an aging population with more
opportunities to make decisions focused on quality of life; and
WHEREAS, The health care system continues to be taxed by a growing population of older, sicker, and a
more resource consuming demographic; and
WHEREAS, Access to advance directives, DNAR orders and living wills are difficult to obtain in the
emergency department setting; and
WHEREAS, Patients’ wishes related to care at the end of life are often not discussed with health care
providers and/or family members which results in a large number of unwanted invasive procedures,
hospital admissions and health care costs;
WHEREAS, Patients, family members and health care providers are frequently unaware of the utility and
benefit of Palliative and Hospice care options available to patients to improve quality of life ; and
WHEREAS, Autonomy is an important guiding principle in the law and in concepts of medical ethics, but
in and of itself is insufficient to capture the full range of complex medical, familial, social, financial,
psychological, cultural, spiritual, religious and legal issues involved in EOL decision making; and
WHEREAS, Significant cultural, political and social barriers hinder a transparent, routine and realistic
approach to preparing for death and dying;
RESOLVED, That the American College of Emergency Physicians encourage palliative and hospice care
consults in the emergency department to increase provider and patient awareness of their utility based on the
patient’s stage of planning; and be it further
Resolution 40(13) Golden Care for Quality of Life
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RESOLVED, That ACEP promote the use of the term “Golden Care” to avoid patient and physician
aversion to discussing goal directed care in seriously ill patients with life-limiting ailments; and be it further
RESOLVED, That emergency physicians respect the dying patient’s needs for care, comfort, and
compassion and employ communication skills that acknowledge the cultural, religious and individual factors that
play into family and patient decision making at the EOL; and be it further
RESOLVED, That ACEP support funding for research related to goal directed care in critically ill
patients, palliative and hospice care in the emergency setting, and better access to advance directives and DNAR
orders in the emergency department; and be it further
RESOLVED, That ACEP’s advocacy initiatives bring more attention to the importance of access to and
enforcement of advance directives and/or DNAR orders and the significant amount of health care dollars that are
spent on unwanted admissions and invasive procedures at the EOL; and be it further
RESOLVED, That emergency physicians lead by example by filing their own advance directives,
discussing their wishes with their family members, and designating a medical power of attorney thereby preparing
themselves to guide patients through this process in a clinical setting.
Background
This resolution calls for the College to encourage palliative and hospice care consults in the emergency
department (ED) to increase provider and patient awareness of their utility based on the patient’s stage of
planning; to promote the use of the term “Golden Care” to avoid patient and physician aversion to discussing goal
directed care in seriously ill patients with life-limiting ailments; for emergency physicians to respect the dying
patient’s needs for care, comfort and compassion and employ communication skills that acknowledge the cultural,
religious and individual factors that play into family and patient decision making at the end of life; to support
funding for research related to goal directed care in critically ill patients, palliative and hospice care in the
emergency setting and better access to advance directives and DNAR orders in the ED; for ACEPs advocacy
initiative to bring more attention to the importance of access to and enforcement of advance directives and/or
DNAR orders and the significant amount of health care dollars that are spent on unwanted admissions and
invasive procedures at EOL; and that emergency physicians lead by example by filling out their own advance
directives discussing their wishes with their family members and designating a medical power of attorney thereby
preparing themselves to guide patients through this process in a clinical setting.
Research shows people want palliative care. Recent public opinion research by the national polling firm Public
Opinion Strategies reveals that even for those patients who are uninformed about palliative care, once they
understand what it is, 92% report they would be highly likely to consider palliative care for themselves or their
families if they had a serious illness. 92% also said they believe patients should have access to this type of care at
hospitals nationwide.
The College has a long history of devoting resources to educate, advocate, and support all aspects of EOL issues.
In 1990, ACEP began encouraging emergency physicians to make information available concerning advance
directives and to distribute materials on these directives, as allowed by state laws, to patients, families, and care
givers. Palliative care is prominently featured in ACEPs Strategic Plan for 2013-2016.
As part of the Choosing Wisely campaign, ACEP has been developing specific recommendations to improve costeffective care and one area of focus has been palliative care.
Hill visits during ACEPs 2013 Leadership and Advocacy Conference included advocating for palliative care.
Resolution 40(13) Golden Care for Quality of Life
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ACEP was instrumental in “end-of-life and palliative care” being added to “The Model of Clinical Practice of
Emergency Medicine” and strongly supported subspecialty certification under the American Board of Emergency
Medicine (ABEM) for Hospice and Palliative Medicine.
The College’s Palliative Medicine Section website provides tools to help physicians recognize the needs of
patients and families struggling with serious illness and to identify opportunities to improve the care for these
patients. Resources include policy and position statements, communication tools, and protocols.
ACEP has worked with Improving Palliative Care in Emergency Medicine (IPAL-EM) to support the practical
aspects of palliative care improvement in emergency medicine. The IPAL-EM portfolio includes materials such
as: Making the Case for ED-Palliative Care Integration, Clinical Practice Guidelines, Getting Started –
Organizing an ED Palliative Care Initiative; Evaluation of the ED-Palliative Care Metrics & Quality, Palliative
Care ED Screening Tool, Consultation Etiquette For Palliative Care in the Emergency Department, Fasts Facts
and Concepts, Emergency Department Management of Hospice Patients, and Initiating a Hospice Referral from
the Emergency Department.
The College has also worked with the Center to Advance Palliative Care to develop ED criteria for palliative care
consideration.
ACEP’s policy statement “Nonbeneficial (“Futile”) Emergency Medical Interventions” states in part, “When
emergency physicians decide to forgo non beneficial treatments especially in the dying patient, special efforts
should be made to maintain communication and to provide comfort, support and counseling for the patient, family
and friends.”
The College’s policy statement “Ethical Issues of Resuscitation” speaks to the emergency physicians’
responsibility as it relates to Do Not Attempt Resuscitation (DNAR) orders and other advance directives (DNR,
DNAR, EMS-DNR POLST, MOLST, etc.)
ACEP’s policy statement “Ethical Issues at the End of Life” states that emergency physicians play an important
role in providing care at the EOL. The tenets of this policy state that the emergency physician should:
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Respect the dying patient’s needs for care, comfort and compassion.
Communicate promptly and appropriately with patients and their families about EOL care choices,
avoiding medical jargon.
Elicit the patient’s goals for care before initiating treatment, recognizing that EOL care includes a broad
range of therapeutic and palliative options.
Respect the wishes of dying patients including those expressed in an advanced directive. Assist surrogates
to make EOL care choices for patients who lack the decision making capacity based on the patient’s own
preferences, values and goals.
Promote liaison with individuals and organizations in order to help patients and families honor EOL,
cultural and religious traditions.
Currently the term “Golden Care” is associated with the long-term care industry. Some members certified in
palliative and hospice medicine expressed concern that the term “Golden Care” would be synonymous with the
elderly, whereas palliative and hospice care are services that benefit all ages of patients with chronic or noncurative diseases or illness.
The American Medical Association (AMA) currently has more than 10 policies regarding end-of-life and
palliative care that are supported by the College.
ACEP Strategic Plan Reference
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective A – Develop and promote delivery models that provide effective and efficient emergency
medical care in different environments.
Resolution 40(13) Golden Care for Quality of Life
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Tactic 13 – Work with IPAL and develop and promote resources on implementation of a palliative
care program in the ED.
Tactic 14 – Develop a script for emergency physicians to use when introducing the concept of
palliative care to a patient/family in the ED.
Tactic 15 – Promote the value of palliative care with emphasis on its value for a patient living with a
chronic non-curative disease. Stress it is not hospice care and it is not withdrawal of
care.
Fiscal Impact
Budgeted staff time and resources to address end-of-life issues.
Prior Council Action
Amended Resolution 31(11) End of Life Care adopted. Directed ACEP to study how emergency medicine can
positively affect end-of-life care, specifically addressing the provision of compassionate and dignified end-of-life
care, and the necessarystewardship of resources; work with other appropriate entities to address patient focused,
compassionate end-of-life care; for the ACEP Board of Directors to update the membership regarding actions
being taken by ACEP on the important topic of end-of-life care.
Amended Resolution 14(09) End of Life Services called for the College to work with other medical organizations
and the federal government to require that all acute care and convalescent hospitals either use an Ethics
Committee or establish an End of Life Committee consisting of physicians, nurses, medical ethicists, religious
leaders, and lay people to determine when care is judged to be non-beneficial. The resolution was referred to the
Board of Directors.
Resolution 30(07) Advanced Directives called for the development of an ACEP approved advance directive form
to be included in syllabus for all ACEP sponsored educational programs. The resolution was referred to the Board
of Directors.
Resolution 18(07) Futile Care called for ACEP to advocate for a federal mandate to establish futile care
committees with a 72 hour mandate for a family to decide about care and payment, develop standards and criteria
for determinations and submit to the AMA for adoption as policy. The resolution was referred to the Board of
Directors.
Substitute Resolution 24(90) Advance Directives and Emergency Medicine called for ACEP to develop or
otherwise obtain for physicians and patient use, written and audiovisual materials explaining the purpose and
utility of advance directives and to investigate the benefits and costs of actively promoting this activity among
both emergency physicians and the public. The resolution was referred to the Board of Directors.
Prior Board Action
Amended Resolution 31(11) End of Life Care adopted.
Referred Amended Resolution 14(09) End of Life Services was assigned to the Emergency Medicine Practice
Committee and the Ethics Committee. Ultimately, the Board agreed with both committees’ recommendation to
take no further action on the resolution and to promote existing ACEP and AMA policy regarding end-of-life
services.
October 2008 reaffirmed “Nonbeneficial (“Futile”) Emergency Medical Interventions” policy statement.
Previously reaffirmed October 2002; originally approved March 1998.
June 2008, approved policy statement “Ethical Issues of Resuscitation.” This statement replaces a policy with the
title “Ethical Issues of Resuscitation” approved October 2001 and “Do Not Attempt Resuscitation (DNAR) in the
Out-of-Hospital Setting” approved September 2003. This policy statement was revised and replaced “‘Do Not
Attempt Resuscitation’ Directives in the Out-of-Hospital Setting,” which was originally approved September
Resolution 40(13) Golden Care for Quality of Life
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1994 and reaffirmed October 1998. The original policy statement was titled “Do Not Resuscitate Orders in the
Prehospital Setting” originally approved June 1988.
June 2008, approved policy statement “Ethical Issues at the End of Life.” Originally approved September 2005.
Referred Resolution 30(07) Advanced Directives was assigned to the Emergency Medicine Practice Committee.
The committee recommended that the Board take no further action on the resolution. The Board approved the
recommendation.
Referred Resolution 18(07) Futile Care was assigned to the Public Affairs staff and the Emergency Medicine
Practice Committee. Recommendations were submitted to the Board and in June 2008 the Board approved the
committee’s recommendations.
October 2003, reviewed the policy resource education paper (PREP) “Do Not Attempt Resuscitation' (DNAR) in
the Out-of-Hospital Setting.” This PREP was an explication of the Policy Statement “'Do Not Attempt
Resuscitation' (DNAR) in the Out-of-Hospital Setting.”
Background Information Prepared By: Marilyn Bromley, RN
Emergency Medicine Practice Director
Reviewed By: Marco Coppola, DO, FACEP, Speaker
Kevin Klauer, DO, EJD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director