Ruby Emergency Department connects families with compassionate palliative care

MORGANTOWN, W.Va. – Now that the season for visiting loved ones is in full swing, the holidays can present a good time for families to talk about wishes regarding their medical care should they face a chronic or serious illness, long before they are in a crisis situation. When a patient arrives in an often-chaotic emergency room, they may or may not be able to participate in making important decisions that can prove overwhelming for family members.

WVU Medicine J.W. Ruby Memorial Hospital is now home to an innovative program that offers palliative medicine consultation services specifically to its Emergency Department (ED) patients. Ruby Memorial is one of only a small handful of hospitals in the United States doing so.

Palliative medicine is a medical specialty that focuses on improving the quality of life of people with illnesses that are usually complex and often terminal. Palliative care providers work with patients, their families, and the rest of the patient’s medical care team to coordinate planning for services like pain management, nutrition, spiritual care, and decision-making regarding life support.

Allison Tadros, M.D., a longtime emergency medicine provider in Ruby’s Emergency Department, saw the ED as a logical connection point to serve individuals and families facing serious or sudden illness and their care needs. In her 20 years working in the ED, Dr. Tadros frequently encountered patients with advanced chronic illnesses, such as heart failure or lung cancer. Others were brought to the ED as the result of a sudden, life-threatening condition like a stroke or severe heart attack.

Whatever the circumstance, important and timely conversations must be navigated so that the patient’s values are understood and wishes respected.

Some situations require immediate care decisions, and a palliative care specialist can serve as a calm presence to guide patients and family members through an emotionally jarring time. For patients with chronic diseases, the palliative care team helps to focus on quality of life by managing symptoms.

Having recognized a need for this expertise in the ED, Tadros paused her emergency medicine career to complete a fellowship in hospice and palliative medicine. After completing the fellowship, she now practices both emergency medicine and palliative care serving as the bridge for this program.

“At times, it can be difficult to predict how things will go for a patient once they are admitted to the hospital with a serious illness, so an initial consultation can establish a relationship with the patient and start a discussion about their goals and values for their medical care. After a few days, patients and their families may face difficult decisions,” Tadros said.

“At that point, they have already met us, and we have established a relationship with the patient and their family. If the patient is sick and unable to communicate themselves, it is the family we are turning to, and it is helpful if we have had multiple conversations with them already, before the time they need to make those decisions.”

Tadros estimated that a slight majority – roughly half – of patients she sees in the Emergency Department have not done any care planning in advance or named a medical power of attorney. Sometimes patients have taken this step, but their personal records are inaccessible.

Pictured left to right: Chris Goode, M.D., Allison Tadros, M.D.,
and R. Osvaldo Navia, M.D.

“If a patient has not already done paperwork naming a medical power of attorney, we offer to do to one. Or if they have done it but it is not documented in their medical chart, we encourage them to bring it in as soon as possible or offer to complete a new one. Patients may already have these documents prepared, but they are in a safety deposit box or filed at home, and it’s not accessible to the healthcare providers in an emergency situation,” Tadros explained.

“As soon as we prepare the form for them, we scan it into the medical record, and it’s immediately available, not only for Ruby Memorial, but at any WVU Medicine clinic or hospital."

In some cases, when a patient cannot communicate their preferences for themselves and have not named a medical power of attorney, providers must make their best guess and name a healthcare surrogate, who may or may not be the person the patient would prefer to make decisions on their behalf. People can struggle to think or talk about advance care planning should they become ill, but a visit to the ED can force the issue and be empowering.

“A visit to the emergency department represents a good time to reflect on where they are with their illness,” Tadros said. “At that point, they may be experiencing a change in their condition, and it is useful to start to think about important decisions like life support and end-of-life wishes.”

Tadros’ unique combination of emergency medicine and palliative care training won the strong support of Chris Goode, M.D., chair of the Department of Emergency Medicine; Nathan M. Lerfald, M.D., chair of the Department of Medicine; and R. Osvaldo Navia, M.D., division chief of Geriatrics, Palliative Medicine, and Hospice.

“The aging population with serious diseases is a growing reality in West Virginia, with more than half of them visiting the emergency department in the last month of life,” Dr. Navia said. “The presence of palliative medicine in the emergency department is changing the dominant paradigm of maintaining life at all costs to a focus on the patient’s goals of care and preference while providing high-quality treatments. Along with few institutions in the nation, WVU Medicine is pioneering the initiative to have a formal clinical plan to adopt palliative care in the emergency department, which is a natural merge given our population’s characteristics.”

Tadros noted that there is a state public health initiative to increase palliative care services in emergency departments statewide, and she hopes to eventually provide this important service to other WVU Medicine emergency departments around the state via telemedicine.

When asked if she had one piece of advice, Tadros’ response was immediate.

“I always tell patients that everyone 18 years and older should have a medical power of attorney completed,” she said. “Have a copy of it available and make sure to give a copy to your medical provider so it can be entered into their medical record well in advance of needing it. Additionally, make sure you and your medical power of attorney have discussed your wishes for your medical care should you become very ill.”

To learn more about WVU Medicine, visit WVUMedicine.org.