Hospice and Palliative Medicine Ultrasound: a New Horizon for Emergency Medicine?

The article by Mariani and Setla¹ in this issue of Academic Emergency Medicine delineates a logical expansion of point-of-care ultrasonography in hospice and palliative medicine, an evolving realm of subspecialty practice. Hospice and palliative care is reserved for patients with chronic conditions that are recognized as beyond cure by all currently available therapeutic interventions. This would seem to be the farthest extreme from the usual paradigm of emergency medicine (EM). However, as the current report demonstrates, palliative care does not mean “no care.” Although the treatment of patients with terminal diseases may not be curative, such patients require management of intercurrent conditions that undermine the quality of the precious time that remains to them before death. Just as patients with known metastatic disease may undergo surgical or pharmaceutical interventions to mitigate the effects of their malignancy without any expectation of cure or even prolonged life expectancy, it is likely that there will be increasing numbers of patients in the terminal phases of incurable diseases who require interventions to relieve focal causes of pain, suffering, or physical or neurologic impairment. Although the use of ultrasound (US) in hospice and palliative medicine has been previously reported,^2–7 it is not a defined part of the model of practice for the subspecialty.⁸

Due to the time-sensitive nature of critical illness, and the delays involved in most forms of diagnostic testing, emergency physicians (EPs) are accustomed to relying solely on the information available from the history and physical examination for medical decision-making. Extensive training in clinical decision-making without the benefit of diagnostic tests equips an EP with the skill sets to provide care in resource-poor settings, as reflected by the existence of EM subspecialties in wilderness, altitude, travel, international, and space medicine. Domiciliary or hospice settings are similarly resource-poor. The leadership of the specialty societies of both Emergency Medicine and of Hospice and Palliative Medicine are to be applauded for recognizing this shared clinical ground, as well as the potential for mutually synergistic benefits as the latter subspecialty grows.

One of the threads of Western medicine has been a quest for information about the inner workings of a patient’s body without physical violation of his or her integument. It is for this reason that the invention of the stethoscope and discovery of radiographic imaging are celebrated as such important developments. The century since the discoveries of the Curies has witnessed enormous refinements in the use of x-rays, the development of computed tomography, and the invention of other imaging modalities such as magnetic resonance imaging and nuclear isotope scanning. A limitation of all these modalities is need for massive, fixed, and expensive structural installations and relatively sophisticated supporting infrastructure, and their reliance on specially trained technicians to obtain images, which are in turn transmitted to and interpreted by dedicated imaging specialists. Until recently, US, although more mobile, was deployed using the same paradigm as other forms of diagnostic imaging. The miniaturization of digital circuitry and other technological advances have resulted in increasingly portable and user-friendly US machines with steadily improving image quality. Like computers, US technology has become progressively less expensive. In the 1960s, when the median house price was $15,000, ultrasound machines cost in excess of $200,000. In 2010, many machines are smaller than a laptop computer, generate better images than the best equipment of two decades ago, and cost less than $40,000. At the time of writing of this commentary, second-hand models of the machine used in the report (which are no longer in production) are available for less than $1,000, and new devices are on the market that easily fit into a lab coat pocket. These advances, combined with the absence of radiation and the need for minimal infrastructural support, have led a variety of analysts, clinicians, and organizations to advocate clinician-performed ultrasonography (also referred to as “clinical ultrasonography”) as the modality of choice for diagnostic imaging in resource-poor settings in both the developing world and industrialized nations.^9–14

The cardinal feature of clinical ultrasonography is that images are both generated and interpreted in real time at the patient’s bedside by the clinician who is caring for the patient. The findings of the imaging study contemporaneously form an integral component of both diagnostic and therapeutic management. Because the clinician is acutely aware of the immediate clinical questions at issue in the patient’s care, the US exam is focused in enquiry and limited in scope. Clinician-performed US frequently addresses clinical syndromes that cut across the regional boundaries traditionally observed by imaging specialists, e.g., “focused assessment by sonography in shock,” which might include the evaluation of the heart, great vessels of the abdomen, lungs, and pleura, depending on the clinical setting and pretest suspicions of the sonologist.

In North America, EM has played the leading role in elucidating the scope and practice of clinical ultrasonography. This role has been driven by the time-sensitive nature of emergent illnesses as well as pressures to improve diagnostic efficiency, reduce exposure to ionizing radiation, conserve the spatial and staffing resources of the ED, and reduce patient throughput times.^15–17 The use of clinical ultrasonography in a hospice to assist in an invasive procedure with potentially serious complications both exploits the advantages of US in resource-poor settings and is a natural extension of its established use in our specialty.

The purpose of a short article such as that by Mariani and Setla is to stimulate thought about potential new directions in the evolution of our specialty practice. As such it is necessarily limited in the answers it provides, but begs questions for further exploration. What areas are particularly suited to hospice and palliative medicine practitioners with a background in EM, and conversely, what areas of weakness do such physicians have? It might be anticipated that EPs would be adept at managing procedural and acute issues, while colleagues from internal medicine or family medicine would be more familiar with the chronic effects of many drugs, such as the burgeoning number of antineoplastic agents. Do patients indeed prefer the arrangement of scanning and treatment at home to the alternative of transport to some form of treatment center, as asserted by the authors?¹⁵ Are there cost savings that arise from this arrangement?^15–17 As usual for analysis of the costs and benefits associated with clinician-performed ultrasonography, it is important to factor in the cost of equipment and training. The cost of training is particularly difficult to assess, because it must be “amortized” over the length of time that the physician uses the learned skill in his or her practice, and the “cost per procedure” varies in inverse proportion to the frequency of its use during that period. Conversely, the costs of the traditional “transport and treat” arrangement are manifold and should include an assessment of the inconvenience and discomfort it inflicts on patients who have made a decision to spend their last days in hospice settings, avoiding where possible the physical and temporal dislocations of our health care system.

As with most of the procedural competencies of our specialty, there is little known about the most effective techniques for imparting knowledge or assessing its acquisition. This problem is particularly challenging with respect to clinical ultrasonography. Unlike skills such as airway management or vascular access, ultrasonography has a range of potential applications that continue to evolve in response to changing clinical settings. In hospice and palliative medicine, these may run the gamut from procedures, to evaluation of specific organs such as the lower extremities for deep vein thrombosis, to as yet undescribed syndromic approaches that will be developed by clinicians caring for this unique group of patients.

While EM has promulgated training guidelines endorsed by the American College of Emergency Physicians (ACEP) in 2001 and 2008,¹⁸ it is unclear which of the applications of wide use in the ED will be of most use in hospice and palliative medicine or, indeed, whether others such as peripherally inserted central catheter line placement, not widely practiced in the ED, might need to be added. The ACEP training guidelines and accreditation process may serve as templates for a customized program of education and continuous quality improvement in hospice and palliative medicine.

In conclusion, the authors are to be congratulated on bringing a potentially interesting extension of the use of clinical US to the attention of our readers. Questions arise regarding the practicability or desirability of such an extension and the degree to which palliative care will resonate with the interests of many EPs. However, this article, by providing a platform for potential areas of growth and collaboration, serves a role that would seem essential to the mission of a scientific specialty journal such as Academic Emergency Medicine.

Editor’s Note: The American Board of Emergency Medicine is one of 10 specialty boards that cosponsored the founding of the formal specialty of hospital and palliative medicine. Over 1200 physicians sat for the inaugural board exam in 2008, and subsequent exams will be held in even-numbered years. Further information is available at the American Academy of Hospital & Palliative Care’s Web site, http://www.aahpm.org