Hrev_master In Italy Emergency Medicine (EM) and Palliative Care (PC) are still considered two opposite disciplines with two opposite end- points: saving lives for EM clinicians, and taking care of end-stage patients for palliative care physicians. According to the WHO, PC is “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual”.1 EM is defined as “a primary specialty established using the knowl- edge and skills required for the prevention, diagnosis and manage- ment of urgent and emergency aspects of illness and injury, affect- ing patients of all age groups with a full spectrum of undifferenti- ated physical and behavioural disorders”.2 Traditionally the domi- nant paradigm in EM has been therapies to maintain life at all costs, often without attention to a patients’ prognosis, treatment values, and preferences for care. This view is deeply flawed and anachronistic, and a change is needed now. To better understand the Italian situation, we need to start with two pieces of evidence. The first is that most of the EM physicians do not receive education in PC during residency or fellowship, even if basic skills and competences in PC are two indispensable key elements in EM, as reported by EUSEM.3 The second evi- dence is that the life expectance is changed in the last two decades and a growing number of older adults living with chronic and inva- liding diseases refers to the ED for worsening clinical and func- tional status, which often occur in the setting of an end-stage dis- ease according to the definition by the SIAARTI document.4 These patients can represent a critical problem for the EM physicians, who may wonder: what can I do for this patient? Which is the best care for this patient, palliative care or intensive care? The answer could be summarized in the principle “the right choice at the right time”,5 aimed at not providing overtreatment all along the end stage of the illness. Even if it is a common thought that most patients with end- stage diseases should stay at home at the end of life, in the reality of the ED three-quarters of these patients visit the ED in the 6 months before their death.6 The crisis of the Italian national health system has further accentuated the difficulty of managing these patients at home.7,8 Nowadays in Italy there is still a great discus- sion in the emergency medical community about the role of the EM in the end-of-life as if the end of life was not an issue to be dealt with in the ED. Since 2010 the Italian law established that suffering is no longer an inevitable issue, and palliative care and pain therapy must be ensured in all care settings, at all stages of life and for any chronic and progressive pathology, for which there are no therapies or, if there are, they are inadequate to stabilise the dis- ease.9 On 31 January 2018, Law No 219 of 22 December 2017, containing “Rules on informed consent and advance treatment arrangements”, came into force,10 and the Italian national register of advanced care planning documents has been active online since February 2020. Any EM physician has to check the advanced care planning document of a non-competent-patient in a serious life- timing condition to abide by and respect the patient’s decisions. EM physicians should be able to consider the true suffering of these patients to treat and solve quickly and correctly uncontrolled symptoms such as pain, dyspnea, and agitation or delirium, avoid- ing overtreatment and offering the best care. Considering the current situation in the Italian EDs and hospi- tals with the shortage of beds and long boarding time,7,8 one possi- ble solution is to transfer the patient to hospice whenever possible, another one is to consider developing a dedicated pathway in the Emergency Care Journal 2022; volume 18:11013 Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044 E-mail: E.Poggiali@ausl.pc.it Key words: Emergency medicine; palliative care; end of life. Acknowledgments: The authors thank Andrea Vercelli, Damiana Muroni, Paola Nassani, Eleonora Rossi, and Il Pellicano Piacenza onlus for their help and support in setting up the relief room; Maria Gaetana Droghi and Valentina Vignola for the communication and training courses for the ED personnel; and Davide Cassinelli for his help in the organisational management. Contributions: EP drafted the manuscript. RB and LO critically revised the manuscript. All the authors approved the final version. Conflicts of interest: EP is member of the editorial board of Emergency Care Journal. This work was not supported by any grant. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it. Ethics approval and consent to participate: Not applicable. Informed consent: Not applicable. Received for publication: 14 November 2022. Revision received: 21 November 2022. Accepted for publication: 21 November 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:11013 doi:10.4081/ecj.2022.11013 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:11013] [page 69] When emergency medicine embraces palliative care Erika Poggiali,1 Raffaella Bertè,2 Luciano Orsi3 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Palliative Care Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy; 3Editor in chief of RICP (Rivista Italiana delle Cure Palliative - Italian Journal of Palliative Care) ED for end-stage patients with refractory symptoms. The ED of Piacenza has created a protocol to identify end-stage patients with uncontrolled symptoms who may benefit from palliative sedation according to a pharmacological schedule designed with the pallia- tive care unit of the hospital, based on morphine for pain and dys- pnea, midazolam for agitation and scopolamine for drying secre- tions, with the aim to improve quality of care for these patients with serious life-limiting illness at the end of their life. These patients, their relatives and care givers can be accommodated in the “relief room” of the ED (Figure 1), that is active since June 2022, to ensure the respect and dignity of the patient, to allow fam- ily members to be able to stay 24 hours a day beside their loved one, in an environment as quiet as possible. We are aware that EM physicians must be able to evaluate the urgency of the patient’s need for treatment based on limited infor- mation in a short time in an often chaotic and difficult context as ED increasingly is, but we also firmly believe that EM physicians need to learn whether, how and when to withhold or withdraw active medical interventions when these are deemed futile, and to engage in discussions regarding end-of-life/palliative care.3 A sub- stantial work has yet to be done in terms of identifying in the ED patients in need of palliative care, training EM clinicians to pro- vide high quality primary palliative care, creating pathways in the EDs for end-stage patients who require palliative sedation. Only when EM embraces PC, including PC principles into ED practice and developing plans of care that consider patients’ values and goals by establishing the in-hospital trajectory of care for patients who are seriously ill, is really possible to take care of the patients focusing on relief of suffering (physical, spiritual, or psy- chological) with an approach based upon patient-determined goals and appropriate for the final phase of a life-limiting condition. References 1. WHO. Palliative care. WHO, 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/palliative- care 2. European Society for Emergency Medicine (EUSEM). Updated definition of emergency medicine in Europe. EUSEM, 2017. Available from: https://eusem.org/news/87- updated-definition-of-emergency-medicine-in-europe 3. EUSEM. European Curriculum of Emergency Medicine. EUSEM, 2020. Available from: https://eusem.org/education/ curriculum/european-curriculum-of-emergency-medicine 4. Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva (SIAARTI). Grandi insufficienze d’organo “end stage”: cure intensive o cure palliative? “Documento con- diviso” per una pianificazione delle scelte di cura. [Major 'end- stage' organ failure: intensive care or palliative care? "Shared document" for planning care choices.] SIAARTI, 2013. Available from: https://www.sicp.it/wp-content/uploads/2018/ 12/2_INSUFFICIENZE_CRONICHE_ENDSTAGE_0.pdf 5. Orsi L, Gristina GR. The right choice at the right time. Minerva Anestesiol 2017;83:436-9. 6. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there [published cor- rection appears in Health Aff (Millwood). 2012 ;31(7):1650]. Health Aff (Millwood). 2012;31:1277-85. 7. Coen D, Casagranda I, Cavazza M, et al. Facing the Emergency Department crisis in Italy. Emer Care J 2’21;17:10331. 8. Poggiali E, Barbieri G, Salvatore V, Salinaro F. The Emergency Rooms and Emergency Medicine should not be the answer to the weakness of the Italian National Health System. Emerg Care J 2021;17:10304. 9. Italian Ministry of health. Disposizioni per garantire l'accesso alle cure palliative e alla terapia del dolore. (10G0056). [Provisions to ensure access to palliative care and pain therapy. (10G0056).] G.U. Serie Generale , n. 65 del 19 marzo 2010. Available from: https://www.trovanorme.salute.gov.it/norme/ dettaglioAtto?aggiornamenti=&attoCompleto=si&id=32922& page=&anno=null 10. Italian Government. LEGGE 22 dicembre 2017, n. 219 Norme in materia di consenso informato e di disposizioni anticipate di trattamento. (18G00006) [LAW No 219 of 22 December 2017 Rules on informed consent and advance treatment arrange- ments. (18G00006)]. (GU Serie Generale n.12 del 16-01- 2018). Available from: https://www.gazzettaufficiale.it/ eli/id/2018/1/16/18G00006/sg Editorial [page 70] [Emergency Care Journal 2022; 18:11013] Figure 1. The relief room in the ED of Piacenza.