Internal Medicine Residents' Beliefs, Attitudes, and Experiences Relating to Palliative Care: A Qualitative Study

Defining Key Elements of a Clinical Experience in Hospice and Palliative Medicine for Medical Residents in the United States

Training in hospice and palliative medicine (HPM) is essential for practicing internists, who routinely care for patients and families facing serious illness. Program directors and medical residents acknowledge the importance of palliative medicine skills, and trainees themselves desire more such training. The ACGME has also recognized the importance of HPM training for medical residents, establishing in its 2022 Common Program Requirements for Internal Medicine a new expectation that all residents have a clinical experience in HPM. However, internal medicine residencies vary significantly in their approach to teaching HPM skills, and what constitutes a useful clinical experience in HPM has not been well-described. In this perspective, we draw from the available literature and our experience as educators to propose 5 core elements for creating an optimal HPM experience for medical residents. These include practice with symptom management and communication in serious illness, exposure to interdisciplinary care, appreciation of the continuum of care settings for HPM delivery, and an understanding of the key principles of hospice care. We then describe the relevance of each element and offer educational strategies regarding how each can be achieved.

End-of-Life Care Education in Pediatric Critical Care Medicine Fellowship Programs: Exploring Fellow and Program Director Perspectives

Background/Objectives: The aim of this study is to describe the current state of end-of-life (EOL) care education within pediatric critical care medicine (PCCM) fellowship programs and explore potential differences in beliefs on EOL care education between program directors (PDs) and fellows. Design: A mixed-methods study based on data obtained through a nationally distributed, web-based cross-sectional survey of PCCM fellowship PDs and PCCM fellows was performed. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowships in the United States. Subjects: PCCM fellows and PDs participated in this study. Measurements and Results: The total number of survey respondents was 124 (94/654 fellows and 30/96 PDs), representing 39% of ACGME-accredited PCCM programs. Bedside teaching and lecture-based modalities were the most commonly used methods to teach EOL care. Most fellows and PDs reported a perceived need for additional EOL education within their respective training programs (fellows 91%, n = 86/94; PDs 67%, n = 20/30). A thematic analysis of curriculum structure questions revealed significant similarities between PDs and fellows, including the perceived need for education in communication, medical management, and cultural awareness. Dealing with uncertainty and resiliency were identified as themes among PDs only, and emotional/moral and legal issues were identified as themes solely by fellows. Conclusions: Our study describes the current state of EOL care education within a sample of PCCM fellowship programs. We highlight the perceived need for additional EOL education and identify areas within EOL care that deserve more focus by PCCM fellows and PDs. Future studies with focus on EOL curriculum development in PCCM EOL training are needed.

General practitioner residents and patients end-of life: involvement and consequences

BACKGROUND

The ageing of the population and the increased number of chronic diseases are associated with an increased frequency of end of life care in hospital settings. Residents rotating in hospital wards play a major part in their care, regardless of their specialty. General practitioner (GP) residents are confronted to such activities in hospital settings during their training. Our aim was to know how they feel about taking care of dying patients, as end-of-life care are very different from the clinical activity they are trained to.

METHODS

We surveyed all GP trainees of "Ile de France". The survey was made of 41 questions regarding advanced directives divided in 7 sections about patients' care, communication, mentoring and repercussion on personal life. The survey was done one time, during two pre-specified days.

RESULTS

525 residents (53.8%) accepted to fulfill the survey. 74.1% of the residents thought that palliative care could have been better. Possible ways of improvements were: a reduction of unreasonable obstinacy (or therapeutic overkill, two terms defined in French law as curative treatment without reasonable hope of efficiency) (59.6%), patient's (210 answers, 40%) and relative's communication (information of patients and relatives about the severity of the disease and risk of death) (199 answers 37.9%). Residents also reported a lack of knowledge regarding end-of-life care specific treatments (411 answers, 79.3%) and 298 (47.2%) wished for better mentoring. Those difficulties were associated with repercussion on their private life (353 answers, 67.2%), particularly with their close relatives (55.4%). Finally, 56.2% of trainees thought that a systematic psychologic follow up should be instituted for those working in "at risk" hospital settings.

CONCLUSION

Self-perception management of dying patients by GP resident emphasize their lack of training and supervision. The feeling of suboptimal care is associated with consequences on personal life.

Medical student experiences and perceptions of palliative care in a middle eastern country

INTRODUCTION

Teaching in palliative care (PC) is an important component of medical education. Yet, studies in many countries document a fragmented and inconsistent approach to PC teaching. The goal of this study is to assess PC education, experience, and comfort levels in providing end-of-life care in recently graduated medical students.

METHODS

A survey was distributed to medical student applicants to residency programs at a large academic medical center in the United Arab Emirates. Descriptive statistics were used to tabulate variable frequencies.

RESULTS

Of 226 surveys, 183 were completed (80.7% response). Over half of respondents (104/183, 56.8%) did not receive any formal PC education or training in medical school. General introduction to PC (64%), pain management (68%), and non-pain symptom management (56%) were the most common topics. Only 13% (24/183) of medical students participated in PC rotations. Only 25% of participants (46/183) reported assessment of PC knowledge or skills. Gender differences were noted, with women more comfortable discussing prognosis (Pearson Chi-square value 8.67, df 3, p < 0.013) and assessing decision-making capacity (Pearson Chi-square value 15.02, df 3, p < 0.005). Few students expressed comfort with any aspect of PC. The majority of respondents (174/183, 95%) felt that it is important to receive PC education in medical school.

CONCLUSIONS

Most newly graduated medical students reported limited education in PC, with minimal clinical experience. The vast majority described a lack of comfort in providing care for dying patients and their families. Educational reform is necessary to embed PC knowledge and skills into medical school curricula.

Perceptions of healthcare professionals towards palliative care in internal medicine wards: a cross-sectional survey

Background

The extension of palliative care services to meet the needs of patients with chronic non-malignant life-limiting conditions faces misconceptions amongst healthcare professionals. A study of prevailing perceptions of healthcare professionals on this wider palliative care service was thus conducted to identify current obstacles, guide the education of local healthcare professionals and improve service accessibility.

Methods

A cross-sectional study was carried out at the Singapore General Hospital. An anonymised and close-ended online questionnaire was disseminated to 120 physicians and 500 nurses in the Department of Internal Medicine. The online survey tool focused on participant demographics; perceptions of palliative care and its perceived benefits; roles and indications; and attitudes and behaviours towards palliative care referrals.

Results

Forty four physicians and 156 nurses suggested that care of terminally ill patients with chronic non-malignant life-limiting conditions are compromised by concerns over the role of palliative care in non-cancer care and lapses in their prognostication and communication skills. Respondents also raised concerns about their ability to confront sociocultural issues and introduce palliative care services to patients and their families.

Conclusions

Gaps in understanding and the ability of nurses and physicians to communicate end of life issues, introduce palliative care services to patients and their families and confront sociocultural issues suggest the need for a longitudinal training program. With similar concerns likely prevalent in other clinical settings within this island nation, a concerted national education program targeting obstacles surrounding effective palliative care should be considered.

Effect of educational intervention on nurses knowledge about palliative care: Quasi-experimental study

The aim of the study was to determine the level of knowledge of registered nurses about palliative care and to determine the effect of educational intervention on this level of knowledge in Turkey. The study was a quasi-experimental study and consists of 136 nurses. The study was conducted between April and June 2019 in a university hospital in Malatya, Turkey. Nurse are educated on the definition, history, and philosophy of palliative care, the responsibilities of palliative care nurses, symptom management, and end of life care. The education was applied in five sessions. Each session took approximately 40 min and sessions were conducted once a week. Data were collected before and after the education via nurse identification form developed by the research team and the Palliative Care Knowledge Test. It was determined that the nurses received 8.9 ± 1.1 out of 20 points before and 17.5 ± 1.9 points after the education. There was a statistically significant difference between the mean scores of nurses before and after training (p < 0.001). It was found that educational intervention has a large effect (Cohen's d = 5.540) on nurses' knowledge about palliative care. It was determined that educational intervention was an effective way to improve nurses' knowledge about palliative care.

Are Internal Medicine Residents Meeting the Bar? Comparing Resident Knowledge and Self-Efficacy to Published Palliative Care Competencies

Background:

There is a need for improved primary palliative care (PC) education and resident comfort with providing end-of-life care.

Objective:

Utilize a new instrument derived from published PC competencies to assess baseline Internal Medicine (IM) resident knowledge and self-efficacy in PC to identify educational gaps and create new PC curricula.

Design:

We created a 2-part instrument including a Knowledge Test (KT) and a Self-Efficacy Inventory (SEI) addressing 18 PC resident competencies across 5 domains: Pain and Symptom Management (PSM), Communication (COMM), Psychosocial, Spiritual, and Cultural Aspects of Care (PSC), Terminal Care and Bereavement (TCB), and Palliative Care Principles and Practice (PCPP).

Setting/Subjects:

The instrument was emailed to IM residents at our institution during academic years 2015-2016 and 2016-2017.

Measurements:

Basic descriptive statistics were performed for the KT and SEI. Mean Rank Analysis and One-way ANOVA were utilized for the KT and SEI, respectively. Congruence was calculated between knowledge and self-efficacy.

Results:

The mean score on the KT was 73% (range 33-80%). There was no significant difference in knowledge among post-graduate year cohorts. Self-efficacy scores were lower for interns overall and in PCPP, TCB, and COMM domains. Knowledge was concordant with self-efficacy in 42% of participants, higher than self-efficacy in 10% of participants, and lower than self-efficacy in 48% of participants.

Conclusions:

For approximately half of respondents, high self-efficacy in PC did not correlate with high PC knowledge. A more focused curriculum is needed to help IM residents facilitate mastery of PC competencies by graduation.

Healthcare providers' views and experiences of non-specialist palliative care in hospitals: A qualitative systematic review and thematic synthesis

BACKGROUND

Healthcare providers working in hospitals are frequently exposed to patients with palliative care needs. For most patients, these reflect non-specialist rather than specialist palliative care needs. Embedding palliative care principles early in patients' disease trajectories within acute care delivery in hospitals, however, is a challenge. How to best understand the experiences of those providing non-specialist palliative care in hospitals has not been systematically assessed.

AIM

To synthesise the evidence on healthcare providers' views and experiences of non-specialist palliative care in hospitals.

DESIGN

A qualitative systematic review and thematic synthesis using Thomas and Harden's thematic synthesis framework.

DATA SOURCES

Databases of MEDLINE, CINAHL, PsycINFO and EMBASE were searched from date of inception to March 2018. Studies were eligible for inclusion if they reported on healthcare providers' views and experiences of non-specialist palliative care in hospitals. Studies were appraised for quality but not excluded on that basis. The review was prospectively registered with the International Prospective Register of Systematic Reviews.

RESULTS

Thirty-nine papers of 37 studies were included, representing 985 hospital healthcare providers' views and experiences. Four major analytical themes emerged; 'Understanding of Palliative Care', 'Complexities of Communication', 'Hospital Ecosystem' and 'Doctors and Nurses - a Different Lens'.

CONCLUSIONS

Non-specialist palliative care in hospitals is operationalised as care in the last weeks and days of life. The organisation of acute care, inter-disciplinary working practices, clinician attitudes, poor communication structures and lack of education and training in palliative care principles exacerbates poor implementation of this care earlier for patients in hospitals.

Palliative care utilization in oncology and hemato-oncology: a systematic review of cognitive barriers and facilitators from the perspective of healthcare professionals, adult patients, and their families

Background

Despite the high potential to improve the quality of life of patients and families, palliative care services face significant obstacles to their use. In countries with high-resource health systems, the nonfinancial and nonstructural obstacles to palliative care services are particularly prominent. These are the cognitive barriers -knowledge and communication barriers- to the use of palliative care. To date no systematic review has given the deserved attention to the cognitive barriers and facilitators to palliative care services utilization.

This study aims to synthesize knowledge on cognitive barriers and facilitators to palliative care use in oncology and hemato-oncology from the experiences of health professionals, patients, and their families.

Methods

A systematic review was conducted. PubMed, PsycINFO, International Association for Hospice and Palliative Care/Cumulative Index of Nursing and Allied Health Literature (IAHPC/CINAHL), and Communication & Mass Media Complete (CMMC) were systematically searched for the main core concepts: palliative care, barriers, facilitators, perspectives, points of view, and related terms and synonyms. After screening of titles, abstracts, and full-texts, 52 studies were included in the qualitative thematic analysis.

Results

Four themes were identified: awareness of palliative care, collaboration and communication in palliative care-related settings, attitudes and beliefs towards palliative care, and emotions involved in disease pathways. The results showed that cognitive barriers and facilitators are involved in the educational, social, emotional, and cultural dimensions of palliative care provision and utilization. In particular, these barriers and facilitators exist both at the healthcare professional level (e.g. a barrier is lack of understanding of palliative care applicability, and a facilitator is strategic visibility of the palliative care team in patient floors and hospital-wide events) and at the patient and families level (e.g. a barrier is having misconceptions about palliative care, and a facilitator is patients’ openness to their own needs).

Conclusions

To optimize palliative care services utilization, awareness of palliative care, and healthcare professionals’ communication and emotion management skills should be enhanced. Additionally, a cultural shift, concerning attitudes and beliefs towards palliative care, should be encouraged.

Providing a liminal space: Threshold concepts for learning in palliative medicine

Introduction: Experience in palliative medicine provides a beneficial learning opportunity for doctors-in-training. There is, however, a gap in understanding which aspects of learning are most useful, which are problematic and how learning can best be facilitated. This study addresses that gap using the 'threshold concepts' framework. Threshold concepts are critical points of learning, often unique to a discipline. The learning occurs within a transitional or 'liminal' space and has specific characteristics including being 'troublesome' and 'transformative.'Methods: A qualitative, exploratory study was carried using the threshold concept framework. Semi-structured focus group interviews were held with doctors-in-training who had undertaken a 6-month palliative medicine attachment. Data were analysed using a content analysis approach with deductive and inductive phases, in order to identify threshold concepts.Results: Five threshold concepts were identified. Two of these, 'emotional engagement' and 'communication management,' displayed all the typical characteristics of threshold concepts. This learning was highly valued by participants, had not occurred elsewhere in training and continued to influence practice.Conclusions: Specific threshold concepts were identified for doctors undertaking a palliative medicine placement. These highlights where specific supports are required for learning and can be used to inform curriculum design.

Palliative and end-of-life care and junior doctors': a systematic review and narrative synthesis

Background

Palliative and end-of-life care is a core competency for doctors and is increasingly recognised as a key clinical skill for junior doctors. There is a growing international movement to embed palliative care education in medical student and junior doctor education. To date there has been no review of the literature concerning the views and experiences of junior doctors delivering this care.

Aim

To review the published literature between 2000 and 2019 concerning junior doctors’ experience of palliative and end-of-life care.

Methods

Systematic literature review and narrative synthesis.

Results

A search of six databases identified 7191 titles; 34 papers met the inclusion criteria, with a further 5 identified from reference searching. Data were extracted into a review-specific extraction sheet and a narrative synthesis undertaken. Three key themes were identified: (1) ‘Significance of death and dying’: all papers found that junior doctors care for many patients approaching the end of life, and this often causes emotional distress and can leave persisting memories for many years afterwards; (2) ‘Thrown in at the deep end’: junior doctors feel unprepared and unsupported in providing palliative and end-of-life care; and (3) ‘Addressing the gaps’: junior doctors often experience a medical culture of disengagement towards dying patients and varying attitudes of senior doctors. Subsequently they have to learn the skills needed through seeking their own opportunities.

Conclusion

Medical education needs to change in order to better prepare and support junior doctors for their role in caring for dying patients. This education needs to focus on their knowledge, skills and attitudes.

Harmonizing Palliative Care: National Survey to Evaluate the Knowledge and Attitude of Emergency Physicians towards Palliative Care.. [DOI: 10.1101/19003939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and Aim

Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians (EPs) and their accessibility to palliative care services in Kuwait. So the aim of this study was to explore the attitude, and knowledge encountered by EPs in providing palliative care in all general hospitals in Kuwait.

Method

A cross-sectional survey was performed in the emergency rooms of all general hospitals in Kuwait using Palliative Care Attitude and Knowledge (PCAK) questionnaire.

Results

Of the total number of physicians working in emergency rooms (n=156), 104 (66.67%) had completed the survey. 76.9% (n=80) of the EPs had either uncertain attitude toward palliative care. Most of the EPs (n=73, 70.28%) didn’t discuss the need of the patients to palliative care either with the patients or their families. Only 16 (15.4%) of the EPs responded correctly to the most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge especially in the most effective management of refractory dysnea (n=18, 17.3%). Experience ≥ 11yrs and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position, and nationality [OR: 5.747 (CI: 1.031-25.00), 1.458(CI: 1.148-1.851); p-value: 0.021, 0.002 respectively]..

Conclusions

Despite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude. Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.

What this paper adds

Studies proved that the emergency room may be a suitable place for early referral of patients who may benefit from palliative care especially old age to prevent upcoming undesired admissions and hospital deaths.

The integration of palliative care concepts and consultation teams into emergency medicine may help to avoid unnecessary and burdensome treatments, tests, and procedures that are not aligned with patients’ goals of care.

Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians and their accessibility to palliative care services in Kuwait.

Recently, a newly developed tool called Palliative Care Attitude and Knowledge (PCAK) questionnaire was created to assess the attitude and knowledge of non-palliative physicians toward palliative care. So the aim of this study was to explore the attitude, and knowledge encountered by emergency physicians in providing palliative care using PCAK 8 in emergency departments in all general

Studies showed that early palliative care consultation was shown to improve quality of life for cancer patients and may even lengthen their survival.

What this study adds

Despite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude.

Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.

Development of palliative care attitude and knowledge (PCAK) questionnaire for physicians in Kuwait

Background

Over the past five decades, palliative care has changed from helping patients at the end of life into a highly dedicated service focused on delivering supportive care to patients with life-limiting illnesses throughout the disease trajectory. To date there is no common agreement on universally applicable measurement tool to know the areas of weakness in physicians’ understanding of palliative care and identifying misconceptions about palliative care. This paper describes the development of a reliable and valid questionnaire to provide a measure of the attitude and knowledge of physicians toward palliative care (PCAK).

Methods

Item pool was generated paying particular attention to content and face validity. The initial version of the questionnaire was piloted and assessed based on psychometric criteria. Items which did not reach acceptable validity were excluded, and the final 37 item version was administered to two groups differing in their palliative care attitude and knowledge on two occasions to assess the construct validity and test-retest reliability. Two hundred thirty two physicians working in primary care clinics and general hospitals completed the questionnaire at the piloting stage. The final version (PCAK) was administered to 35 oncologists and 76 physicians. SPSS v20 was used for statistical analysis.

Results

Of the Pilot study, 20 items were excluded because didn’t meet the criteria for item difficulty and discrimination. Item-to-total-score correlations (r) was ranging from 0.347 up to 0.806. Internal consistency (Cronbach’s alpha) was high ranging from 0.636 to 0.824. While testing the final PCAK, oncologist scored consistently higher than the other physicians on all sections of the questionnaire (P < 0.001) suggesting good construct validity. Test to retest reliability for each section was very high, ranging from 0.879 to 0.97 and the overall reliability was 0.95. The internal consistency reliability of each section was very good ranging from 0.681 ± 0.893.

Conclusion

The findings demonstrate that PCAK meets psychometric criteria for reliability and construct validity. It provides a useful scale to assess the attitude and knowledge of physicians about palliative care helping in planning of educational programs for physicians.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0430-9) contains supplementary material, which is available to authorized users.

Knowledge and Self-Efficacy Assessment of Residents and Fellows Following Palliative Care Unit Rotation: A Pilot Study

BACKGROUND

In Germany, some units of specialized palliative care (SPC) offer a 6- to 12-month rotation for resident physicians (RPs) and fellows from different specialties.

OBJECTIVE

This pilot study aimed to evaluate feasibility of assessing palliative care knowledge (PCK) and palliative care self-efficacy (PCSE) using a paper-based questionnaire.

METHODS

Palliative care knowledge and PCSE were assessed by introducing a score, followed by a descriptive analysis (determination of frequency, mean, median, and range) using nonparametric tests (χ² test, Mann-Whitney U test).

RESULTS

We assessed 17 RPs following SPC rotation and 16 board-certified specialists (BCSs) who had no experience in SPC from 3 German comprehensive cancer centers. Resident physicians were predominantly enrolled in residency programs of hematology and oncology (n = 6), anesthesiology (n = 6), and psychosomatic medicine (n = 3). Resident physicians rotated between year 1 and 8 of residency. Fifteen RPs (88%) had elected this rotation and 72% preferred 12-month duration. The total PCK score of PCK was 27 (RPs) and 24 (BCSs; P = .002). Mean PCSE scores were 46 (RPs) and 39 (BCSs; P = .016). Of 71% of RPs, only 27% of BCSs knew how support of hospice service was initiated ( P = .004). Participants rated the items as comprehensible (n = 24; 73%), relevant (n = 25; 76%) and the questionnaire as adequately long (n = 23; 70%).

CONCLUSION

An improved PCK and PCSE were observed in physicians who rotated through an SPC unit; this resulted in an increased tangibility of local palliative care and hospice services. The questionnaire was comprehensible, relevant in terms of content, and adequate in length for a prospective multicenter survey.

Health Professionals Perceived Concerns and Challenges in Providing Palliative and End-of-Life Care: A Qualitative Analysis

Background:

The Institute of Medicine identifies that quality palliative/end-of-life (EOL) care should be provided to patients with serious, life-limiting illnesses and their families by competently prepared health professionals.

Purpose:

This study assessed perceived concerns of health professionals pertaining to the delivery of palliative/EOL care in the hospital setting. The specific aim was to determine thematic concerns in the delivery of palliative/EOL care which emerged from respondents’ impressions of a memorable palliative/EOL patient experience.

Methods:

Interdisciplinary health professionals at a large academic health system in the Midwest were surveyed to reflect upon a memorable palliative/EOL life care patient situation (positive or negative). A Thematic Analysis approach was used to code qualitative responses to 4 open-ended questions and then extract themes and subthemes from the coded data.

Results:

Concerns identified by participants (N = 425) emerged around 7 themes including communication (97%), decision-making/care planning (75%), education needs (60%), EOL care (48%), ethics (24%), satisfaction with care (9%), and spiritual/cultural sensitivity (6%).

Conclusion:

Challenges exist in the delivery of quality palliative/EOL care in the hospital setting which may be addressed through educational initiatives that focus on recognition of cultural influences on care preferences, improving communication between patients/families and providers, education about the differences between palliative and EOL care, and increased competency of health providers in having EOL/goals-of-care discussions. Health professionals must recognize the benefit of collaborative palliative care in order to meet patient and family needs holistically and comprehensively.

Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND

Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED).

OBJECTIVE

The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED.

METHODS

Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement.

CONCLUSION

Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.