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Understanding preferences for ventilation and resuscitation has become especially important during the COVID-19 pandemic, as a patient's respiratory status may deteriorate quickly. While intubation can be reflexive for patients with “full code” status, invasive mechanical ventilation is associated with complicated and prolonged courses that many patients may not survive. Busy emergency clinicians may not have time to devote to goals-of-care conversations, particularly when the volume and acuity of patients are high.
These authors report the experience of a New York City emergency department (ED) that implemented a palliative care response team during the pandemic. Clinicians consulted the team for clarification of goals of care and when a patient's prognosis did not align with their code status. The authors report outcomes for 110 patients (median age, 81.5 years) with ED-based palliative care consults, most of whom did not have decision-making capacity on arrival. Initially, 83% of patients had full code status; however, this decreased to 18% after the consults. At hospital discharge or death, 52% of patients had comfort-directed care status and only 9% had full code status.
Lee J et al. Early intervention of palliative care in the emergency department during the COVID-19 pandemic. JAMA Intern Med 2020 Jun 5; [e-pub]. (https://doi.org/10.1001/jamainternmed.2020.2713)
Comment
In this small study, most patients (or their surrogate decision makers) changed their code status to restrict invasive measures after a goals-of-care conversation with the palliative care consult team. Although emergency clinicians routinely lead these conversations, a specialized consult team is likely better able to dedicate uninterrupted time to explore values and preferences while aligning these with the patient's current clinical picture. This team could be a valuable addition to any busy ED, even outside the COVID-19 pandemic.