Hrev_master Abstract In the last decades emergency physicians have observed a steep increase in the emergency department (ED) admissions of palliative care patients who rely on the hospital for symptoms’ relief and management of acute exacerbations of their chronic dis- ease. Previous studies have suggested that palliative care interven- tions in the ED could prevent unnecessary admissions and reduce both the length of hospitalization and costs. However, emergency medicine physicians might have limited specialistic education and resources to provide a correct management of palliative care patients and avoid futile interventions. Thus, we aim in this narra- tive review to provide the reader with an introduction on the prin- ciples that should guide the emergency physician in a correct approach to palliative care patients in the ED. We will explain how to deal with the intrinsic prognostic uncertainty of palliative care patients by implementing a correct ethical approach which encom- passes the understanding of both appropriateness and futility of intervention; furthermore, we will present practical tools such as scores and trials. Introduction In the last decades, the median age of the world population has rapidly grown due to a steep decline in the birth rates and an increase in life expectancy.1 The World Health Organization has estimated that between 2015 and 2050 the number of people older than 60 years old will double, and by 2050 worldwide there will be more than 400 mil- lion people over 80 years old.1 The consequences of this demographic shift are devastating with an exponential use of the healthcare resources toward the end of life.3,4 Emergency departments (EDs) are especially affected by this phenomenon with a growing number of patients who present to the hospital not for acute problems, but for symptom relief and management of chronic diseases.5 Among them, palliative care patients compose a high percentage, which is slowly increasing year after year.6,7 Even though previous studies have sug- gested that palliative care interventions in the ED could prevent unnecessary admissions and reduce both the length of hospitalization and costs, emergency medicine physicians, especially residents and young doctors, might have limited specialistic education and resources to provide a correct management of palliative care patients.8 This lack of knowledge and practice has been highlighted by the COVID-19 pandemic, during which the increased demand for emergency department services resulted in limited resources and staff to provide quality palliative care. The situation clearly demonstrated that, especially during times of crisis, emergency department proto- cols should incorporate palliative care and seek innovative tools which can allow for better management of palliative care patients and emotional/spiritual support of families.9,10 Thus, we aim in this narra- tive review to provide the reader with an introductory guide on the ethical and practical principles that should guide the emergency physician in a correct approach to these patients in the ED.11-15 Uncertainty and how to deal with it Doctors are historically taught to understand patients through scientific knowledge, basing their decisions on scientific evidence alone so that subjectivity does not bias their judgment. Even though this technical approach is very efficient for disease management, it is not adequate to deal holistically with another human being, espe- cially in situations of suffering or dealing with possible fatal out- comes. In these cases, the assembly line of the industry of health- care fails and both the patient and the doctor find themselves impo- tent, especially in front of death. The difficulties of managing pal- liative care patients can stem from the intrinsic uncertainty of death. In fact, while centuries ago death was typically sudden and unex- pected, now it is usually the delayed final event in a prolonged course of a chronic disease, during which a correct prediction can be impossible. These delicate situations require a “humane” doctor who applies the scientific evidence and skills with ethical sensitiv- ity and insight, trying to understand the patient’s biography.16 Doctors need to combine the scientific knowledge of disease and Emergency Care Journal 2023; volume 19:11308 [Emergency Care Journal 2023; 19:11308] [page 31] A narrative review on palliative care in the emergency department: dealing with the uncertainty of death Lorenzo Porta,1,2 Eugenia Mauri1,2 1School of Medicine and Surgery, University of Milano-Bicocca, Milan; 2Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy Correspondence: Lorenzo Porta, Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milan, Italy. Tel.: +39.3470611396. E-mail: lorenzo.porta1992@gmail.com Key words: palliative care, emergency department, death, medical ethics, appropriateness. Contributions: all the authors made a substantive intellectual contri- bution, read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. Ethics approval and consent to participate: not applicable. Received for publication: 13 March 2023. Accepted for publication: 16 May 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11308 doi:10.4081/ecj.2023.11308 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, 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 manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly treatments with the understanding that each patient might need dif- ferent approaches and interventions. In fact, physicians should pur- sue a personalization of the healing process which aim to maximize the benefits for each patient based on their own values and narra- tives.17,18 In the following chapters we will explain how emergency medicine physicians can deal with the intrinsic uncertainty of death trajectories, assessing patients in a multimodal and holistic approach that encompasses both active emergency medicine and palliative care, avoiding futile interventions and providing the finest support to the patient and family. We will illustrate death trajecto- ries and how to apply ethical reasoning, scores, and trials to navi- gate through the uncertainty of death. Given the aim and scope of our research, we will not present and review the use of drugs in the palliative care. However, given the great importance of the topic, we will provide the reader with some bibliographic sources which can be used as a basis for further studies.19-21 Death trajectories Four common death trajectories have been identified and understanding them can help the emergency medicine physician to position every patient on the course of its disease, avoiding futile intervention and promoting correct palliative care interven- tions.22 The known trajectories, as displayed in Figure 1, are: i) sudden death: instantaneous or after a brief episode of an acute illness (e.g., infection, trauma, cardiac arrest, stroke). This trajec- tory does not allow for any planning of palliative care interven- tions; ii) short period of evident decline: predictable decline in physical health over a period of weeks, months, or years (e.g., cancer), with a progressive reduction in the performance status especially in the last months. This trajectory allows for early pal- liative care interventions and, in the last months of life, a more intense palliative approach, if necessary; iii) long term limita- tions with intermittent serious episodes: long course of disease (e.g., heart failure, chronic obstructive pulmonary disease) with occasional acute, possibly lethal, exacerbations generally associ- ated with hospitalization and intensive treatment. After each episode, the patient experiences a deterioration in health and functional status; iv) prolonged dwindling: progressive disability from an already low baseline of cognitive or physical functioning (e.g., Alzheimer’s dementia, frailty), characterized by a progres- sive and long loss in functional capacity until a final event, which results fatal due to the declined physical reserves. Cultivating a medical ethical approach Since the birth of the medical job, ethics has been an integral part of the profession, serving as a moral compass which allowed the physician to sail through the uncharted waters of disease and death. With the advancement of medicine, we have started to rely more on the scientific reasoning, relegating ethics to just anecdot- ical cases. However, nowadays more than ever the physician must face ethical problems which stem from the modernity of medicine (e.g., death, abortion, euthanasia, privacy, healthcare accessibili- ty). This situation is especially poignant in intensive care depart- ments, where severe complications are common, and doctors must take complex decisions regarding prognosis, death, and pal- liation. Thus, it is crucial to learn medical ethics to approach patients without getting lost in the rush of the “necessity to act”. Medical ethics, as explained by Beauchamp and Childress, is supported by four main principles: autonomy, beneficence, non- maleficence, and justice that every doctor should always follow to ensure proper care. The principle of autonomy asserts the right of every patient to make informed decisions about their healthcare. In the emergency department, this can be pursued by direct con- frontation with the patient or, in case of unconsciousness or states not fit to make decisions for themselves, by talking with family members or legal guardians. Beneficence refers to the principle of acting in the best interest of the patient, while non-maleficence refers to the principle of doing no harm. Medical professionals need to balance the risks and benefits of treatment options, being aware of potential risks and taking appropriate measures to prevent further harm to the patient. Lastly, justice refers to the principle of fairness. Doctors need to ensure that all patients receive fair and equitable care, regardless of their socio-economic status or other factors, and need to be aware of potential systemic or personal biases and work to address them.23,24 Appropriateness and futility Vergano et al. illustrated clearly that intensive care physicians (such as emergency medicine doctors) should always evaluate both appropriateness and futility when considering an intervention.25 Appropriateness is defined as the degree to which a provided med- ical intervention is beneficial to the clinical needs, given the cur- rent best evidence. To assess the clinical adequacy of a procedure, doctors must consider both the scientific pertinence and the ethical proportionality, meaning the impact on both the patient’s biology and biography. This holistic approach allows patients to be offered only clinically adequate interventions, and to decide whether these proposals are meaningful within the context of their personal life narrative and values.25 In this perspective, the limit of acting is determined by the futility of our intervention, defined as the gap between the highest level of functioning achievable by medical care and the lowest quality of life acceptable to the patient.26 Surprise question To raise concern and help identify patients who might benefit from hospice and palliative care, Dr. Joanne Lynn in 2005 Review Figure 1. Death Trajectories. X axis, time; Y axis, performance status. [page 32] [Emergency Care Journal 2023; 19:11308] Non -co mmerc ial us e o nly designed the following question every doctor can ponder on: would I be surprised if this patient died in the next 12 months? This approach has been shown to limit the physician’s tendency to over- estimate prognosis in all clinical settings, while being effective in identifying end-stage renal disease and patients with cancer who are at an increased risk of mortality.27-30 Regarding the ED, the study from Zeng et al. demonstrated that trained emergency medicine physicians were able to increase their perceived ability to determine life expectancy, leading to a statistically significant increase in ED-generated palliative care consults.31 However, the surprise question was designed for a primary care and ward set- tings, and mostly for neoplastic patients. Thus, its applications could be limited in the emergency medicine setting, where it could need to be modified shortening the period of time to account for the acute presentation of the patient and the possible underestima- tion of prognosis due to critical condition of arrival. Scores Scores provide a standardized and objective way to assess patient needs, ensuring the most appropriate and effective care possible, however they may not capture all the nuances of a patient’s clinical condition or personal preferences, and healthcare providers must always use their clinical judgment in conjunction with scores to ensure the best possible care. Among the different scores applied to palliative care, the palliative performance scale (PPS) has been demonstrated to be a useful outcome-prediction tool and its use has been widely validated to assess the functional status of seriously ill patients. The PPS rates the patient with a score from 0 to 100, based on the ability to perform activities of daily living, such as eating, dressing, and bathing, as well as their ability to ambulate and communicate (Table 1). As demonstrated by Babcock et al., PPS can be applied in the ED setting for risk stratification and early palliative care referral of patients.32-35 Similar results emerged from the meta-analysis by Downing et al. that illustrated that the functional status of palliative patients in the ED correctly predict survival.36 Another useful score in the emer- gency department is the Palliative Care Rapid Emergency Screening (P-CaRES) which involves identifying patients with life-limiting conditions and two or more unmet palliative care needs (Table 2). If positive, palliative care consultation is indicat- ed. This tool has demonstrated validity, reliability, and acceptabil- Review Table 1. Palliative Performance Scale (PPS), version 2. PPS level Ambulation Activity level and Self-care Intake Level of (%) evidence of disease consciousness 100 Full Normal; no evidence of disease Full Normal Full 90 Full Normal; some evidence of disease Full Normal Full 80 Full Normal with effort; some evidence of disease Full Normal or reduced Full 70 Reduced Cannot do normal job; significant disease Full Normal or reduced Full 60 Reduced Cannot do hobbies; significant disease Occasional assistance needed Normal or reduced Full or confusion 50 Mainly sit/lie Cannot do any work; extensive disease Substantial assistance needed Normal or reduced Full or confusion 40 Mainly sit/lie As above Mainly assisted Normal or reduced Full or drowsy +/- confusion 30 Bed bound As above Total care Normal or reduced Full or drowsy +/- confusion 20 Bed bound As above Total care Minimal to sips Full or drowsy +/- confusion 10 Bed bound As above Total care Mouth care only Drowsy-coma +/- confusion 0 Death - - - - [Emergency Care Journal 2023; 19:11308] [page 33] Table 2. Palliative care and rapid emergency screening tool (P-CaRES). Does the patient have a life-limiting illness? Advanced dementia or CNS disease (e.g., history of stroke, ALS, Parkinson): assistance needed for most self-care and/or minimally verbal. Advanced cancer: metastatic or locally aggressive disease. End stage renal disease: on dialysis or with a creatinine > 6 mg/dL. Advanced COPD: continuous home o2 therapy or chronic dyspnea at rest. Advanced heart failure: chronic dyspnea, chest pain or fatigue with minimal activity or rest. End stage liver disease: history of recurrent ascites, GI bleeding or hepatic encephalopathy. Septic shock: with the necessity of ICU admission and significant pre-existing comorbid illness. Provider discretion – high chance of accelerated death (e.g., advanced AIDS, major trauma or hip fracture in elderly). If nothing above applies, stop screening ≥1 items above: continue screening Does the patient have two or more unmet palliative care needs? Frequent visits: ≥ 2 ed visit or hospital admissions in the past 6 months. Uncontrolled symptoms: visit prompted by uncontrol symptoms, such as dyspnea, depression, fatigue, pain etc. Functional decline: loss of mobility, frequent falls, skin breakdown, etc. Uncertainty about goals of care and or caregiver distress: caregiver cannot meet long-term needs; distress about goals-of-care. Surprise question: positive answer. <2 items above: stop screening ≥2 items above: recommend palliative care consultation Non -co mmerc ial us e o nly ity by palliative care specialists and emergency medicine clini- cians. Furthermore, in addition to identifying patients with unmet palliative care needs who might benefit from a palliative care con- sultation, the P-CaRES tool was shown to predict 6-month survival and was highly correlated with PPS values.37-39 In the emergency department, another useful tool that can be applied is the NECPal scale, which has been extensively validated to quickly and prompt- ly identifying patients with palliative care needs, especially in the family medicine field. The scale was developed by Carvajal et al. and has been validated in several studies, demonstrating good reli- ability and validity.40 The use of the NECPal scale allows health- care professionals to tailor symptom management interventions to individual patient needs, improving patient outcomes and satisfac- tion with care. A study by Gómez-Batiste et al. found that the implementation of the NECPal scale in palliative care practice led to a reduction in symptom burden and improved patient comfort.41 Trials Another useful approach to palliative care patients in the ED is by implementing trials, which could be time-limited, skill-limited or event limited. Trials are an agreement between clinicians and a patient/family to use a certain level of medical therapies (skill-lim- ited) over a defined period (time-limited) to see if the patient improves or deteriorates according to agreed-on clinical outcomes, with the possibility to prematurely shift the cure to palliative sup- port in case of certain severe complications of which risks seem to outweigh the benefits (event-limited). Physician can resort to trials to delay the dichotomous decision between palliative and active care, securing the opportunity to evaluate in time potentially bene- ficial interventions, with a thorough consideration of its risks and benefits. The application of trials can allow to gather biographical data which facilitate the process of understanding the patient’s lim- its of the ethical proportionality of interventions, avoiding futile actions, and preparing in case for a shift toward comfort-focused end-of-life care.42 Confusion about palliative care in the ED Even though previous studies reported that early palliative care interventions allow not only for a better quality of life, but also for an extension in the duration of life itself, confusion and obstruc- tionism in the ED among emergency physicians are still com- mon.43 In fact, palliative sedation, withdrawal of life support treat- ments and euthanasia are wrongly used as synonyms, when they have different meaning and intentions. Palliative sedation is the act of making a patient calm, unaware, or unconscious using pharma- cological therapy to relieve suffering from symptoms that cannot be controlled with other treatments (refractory symptoms). Previous research has thoroughly demonstrated that palliative sedation neither causes acceleration in the dying process nor antic- ipates death.44-48 Withdraw of life support treatment means the removal of interventions that are no longer indicated because of a lack of clinical or subjective benefit. Euthanasia is the practice of intentionally terminate life to eliminate pain and suffering. It is important to emphasize these differences not for lexical justice, but because of the distinctive aims they have. In fact, while euthanasia aims to end the patient’s life and is caused actively by the physi- cian, withdrawing and palliative sedation aim to remove burden- some interventions and relieve symptoms, following the two prin- ciples of medical ethics of beneficence and non-maleficence.49 The emergency physician must be conscious that all the decisions regarding palliative care in the emergency department must be dis- cussed with the patient, his/her family or caregivers, the nurses, and, in case of doubts shared with palliative care specialists. In fact, a clear communication is vital to successfully start to build the patient–physician trust and to start a palliative care plan. Furthermore, the creation of joint palliative care pathway and pro- tocols (created by the whole emergency department together with palliative care specialists) can allow for early identification of pal- liative care patients, implementation of simultaneous care and bet- ter management of symptoms, and palliative care sedation, while reducing the responsibility and stress of the decision of the single physician. For what concerns communication, every component of the emergency department should be trained in a correct lexicon use, communication modality and non-verbal approach, which cannot and should not be improvised but must be obtained by fol- lowing a specific learning process. Current situation in Italy Regarding the current situation in Italy, the emergency physi- cian should be aware and informed of two laws which regulate the application of palliative care in healthcare: D. lgs 38/2010 and D. lgs 219/2017. The first one dictates that palliative care should be implemented in every field of healthcare, including the emergency department, considering especially diseases with chronic or fatal evolution. This law allowed for a redefinition of the assistance models, the creation of specific palliative care networks, better access to palliative care drugs and an advancement in pediatric pal- liative care. The second law regulates the informed consent, stating that every patient has the right to know his/her health status and be informed thoroughly of his/her conditions, including the possibili- ty of refusing every single intervention proposed. This law allowed for the creation of a National Bank for the registration of advanced treatment instructions (Disposizioni Anticipate di Trattamento – DAT) which enable every adult person to auto-determinate him/herself by expressing his/her will on possible medical inter- ventions. The bank grants the accessibility of the instructions, and it is compulsory for every doctor to verify the patient’s directives and adhere to them. Several organizations must be cited for their extensive work to apply palliative care in the emergency department in Italy: SICP (Società Italiana di Cure Palliative), SIAARTI (Società Italiana Anestesia, Analgesia, Rianimazione e Terapia Intensiva), SIMEU (Società Italiana Medicina d’Emergenza Urgenza) ed EUSEM (European Society for Emergency Medicine). SICP’s main objec- tive is the diffusion, application and education on palliative care in every field of medicine, conveying a holistic vision of the heal- ing process where the patient is at the center. SIAARTI, SIMEU and EUSEM focus on the promotion and application of a correct medical expertise in the field of intensive medicine. They advo- cate that even in intensive care departments palliative care patients deserve to be assisted properly with the aim of preserving the patient’s dignity, autonomy, and control at the end of life. A virtuous example of palliative care in the ED is the “relief room” of Piacenza Hospital, a place where end-stage patients, identified by a specific protocol21 by emergency physicians, can receive pal- liative sedation or symptomatic relief while surrounded by family members who can stay all day beside their loved one, in a quiet, private environment.15 Review [page 34] [Emergency Care Journal 2023; 19:11308] Non -co mmerc ial us e o nly Conclusions We strongly believe emergency physicians need to integrate palliative medicine more into their daily practice, embracing a more holistic approach to patients, that can be acquired through the study and application of ethics and humanities in medicine. To help this process of assimilation, palliative medicine should become part of the training for emergency medicine physicians. References 1. UN Department of Economic and Social Affairs, Population Division: World Population Ageing 2013. UN, 2013. 2. WHO’s Global Health Estimates (GHE) World Health Organization. 2019. Available from: https://www.who.int/data/ global-health-estimates 3. Kardamanidis K, Lim K, Da Cunha C, et al. Hospital costs of older people in New South Wales in the last year of life. Med J Aust 2007;187:383-6. 4. 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. Health Aff (Millwood) 2012;31:1277-85. 5. Da Silva Soares D, Nunes CM, Gomes B. Effectiveness of emergency department based palliative care for adults with advanced disease: a systematic review. J Palliat Med 2016; 19:601-9. 6. Cervellin G, Casagranda I, Ricci G, et al. Unavoidable deaths in the Italian Emergency Departments. Results of a ten-year survey. A mirror of substantial social changes, or a warning for a hospital-system pathology? Emerg Care J 2017;13:6718. 7. Elmer J, Mikati N, Arnold RM, et al. Death and End-of-Life Care in Emergency Departments in the US. JAMA Netw Open 2022;5:e2240399. 8. Wang DH, Breyre AM, Brooten JK, Hanson KC. Top ten tips palliative care clinicians should know about improving part- nerships with emergency medical services. J Palliat Med 2023;26:704-10. 9. Bowman JK, Aaronson EL, Petrillo LA, Jacobsen JC. Goals of care conversations documented by an embedded emergency department-palliative care team during COVID. J Palliat Med 2023;26:662-6. 10. European Society For Medical Oncology. Available from: https://www.esmo.org/covid-19-and-cancer/covid-19- resource-centre/covid-19-palliative-care-pathways 11. Grudzen CR, Stone SC, Morrison RS. The palliative care model for emergency department patients with advanced ill- ness. J Palliat Med 2011;14:945-50. 12. Stone SC, Mohanty S, Grudzen CR, et al. Emergency medicine physicians' perspectives of providing palliative care in an emergency department. J Palliat Med 2011;14:1333–8. 13. Smith AK, Fisher J, Schonberg MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 2009;54:86–93.e1 14. O'Connor AE, Winch S, Lukin W, Parker M: Emergency medicine and futile care: Taking the road less travelled. Emerg Med Australas 2011;23:640-3. 15. Poggiali E, Bertè R, Orsi L. When emergency medicine embraces palliative care. Emerg Care J 2022;18:11013. 16. Downie RS, Macnaughton J. Clinical judgement: evidence in practice. Oxford, Oxford University Press, 2000. 17. Macnaughton J The humanities in medical education: context, outcomes and structures Medical Humanities 2000;26:23-30. 18. Orsi L, Gristina GR. The right choice at the right time Minerva Anestesiologica 2017;83:436-9. 19. Beller EM, Driel ML van, McGregor L, et al. Palliative phar- macological sedation for terminally ill adults. Cochrane Database of Systematic Reviews 2018. 20. De Iaco F, Gandolfo E, Guarino M, et al. Terapia del dolore in Urgenza e Sedazione Procedurale. Amazon self publishing. Chapter 14. 2022. 21.https://www.sicp.it/aggiornamento/linee-guida-bp-proce- dures/2022/06/sala-del-sollievo-e-sedazione-palliativa-mala- to-end-stage-con-sintomi-refrattari-nel-dea/ 22. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005;330:1007-11. 23. Beauchamp TL, Childress JF. Principles of biomedical ethics. New York: Oxford University Press; 2001. 24. American College of Emergency Physicians. Code of ethics for emergency physicians. Accessed March 8, 2023. Available from: https://www.acep.org/globalassets/sites/acep/media/by- medical-focus/ethics/code-of-ethics-for-emergency-physi- cians.pdf 25. Vergano M, Magavern E, Zamperetti N. Clinical ethics: what the anesthesiologist and the intensivist need to know. Minerva Anestesiol 2018;84:515-22. 26. Hinshaw DB, Pawlik T, Mosenthal AC, et al. When do we stop, and how do we do it? Medical futility and withdrawal of care. J Am Coll Surg 2003;196:621-51. 27. Moss A, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc of Nephrol 2008;3:1379-84. 28. Moss A, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med 2010; 13:837-40. 29. Haydar S, Almeder L, Michalakes L, et al. Using the surprise question to identify those with unmet palliative care needs in emergency and inpatient settings: what do clinicians think? J Palliat Med 2017;20:729-35. 30. Mitchell G, Senior HE, Rhee JJ, et al. Using intuition or a for- mal palliative care needs assessment screening process in gen- eral practice to predict death within 12 months: a randomised controlled trial. Palliat Med 2018;32:384-94. 31. Zeng H, Eugene P, Supino M. Would you be surprised if this patient died in the next 12 months? Using the surprise question to increase palliative care consults from the emergency depart- ment. J Palliat Care 2020;35:221-5. 32. Babcock M, Gould Kuntz J, Kowalsky D, et al. The palliative performance scale predicts three- and six-month survival in older adult patients admitted to the hospital through the emer- gency department. J Palliat Med 2016;19:1087-91. 33. Harrold J, Rickerson E, Carroll JT, et al. Is the palliative per- formance scale a useful predictor of mortality in a heteroge- neous hospice population? J Palliat Med 2005;8:503-9. 34. Head B, Ritchie CS, Smoot TM. Prognostication in hospice care: Can the palliative performance scale help? J Palliat Med 2005;8:492-502. 35. Morita T, Tsunoda J, Inoue S, Chihara S. Validity of the pallia- tive performance scale from a survival perspective. J Pain Symptom Manage 1999;18:2-3. 36. Downing M, Lau F, Lesperance M, et al. Meta-analysis of sur- vival prediction with palliative performance scale. J Palliat Care 2007;23:245-52; discussion 252-4. 37. Paske JRT, DeWitt S, Hicks R, et al. Palliative care and rapid Review [Emergency Care Journal 2023; 19:11308] [page 35] Non -co mmerc ial us e o nly emergency screening tool and the palliative performance scale to predict survival of older adults admitted to the hospital from the emergency department. Am J Hosp Palliat Care 2021;38: 800-6. 38. Bowman J, George N, Barrett N, et al. Acceptability and relia- bility of a novel palliative care screening tool among emergen- cy department providers. Acad Emerg Med 2016;23:694-702. 39. Tan A, Durbin M, Chung FR, et al. Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER). BMC Med Inform Decis Mak 2020;20:13. 40. Calsina-Berna A, Amblàs Novellas J, González-Barboteo J, et al. Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital. BMC Palliat Care 2022;21:210. 41. Gómez-Batiste X, Martínez-Muñoz M, Blay C, et al. Utility of the NECPAL CCOMS-ICO© tool and the Surprise Question as screening tools for early palliative care and to predict mortality in patients with advanced chronic conditions: A cohort study. Palliat Med 2017;31:754-63. 42. VanKerkhoff TD, Viglianti EM, Detsky ME, Kruser JM. Time- limited trials in the intensive care unit to promote goal-concor- dant patient care. Clin Pulm Med 2019;26:141-5. 43. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 2010;363:733-42 44. Bozzaro C, Schildmann J. "Suffering" in palliative sedation: conceptual analysis and implications for decision making in clinical practice. J Pain Symptom Manage 2018;56:288-94. 45. Prado BL, Gomes DBD, Usón Júnior PLS, et al. Continuous palliative sedation for patients with advanced cancer at a ter- tiary care cancer center. BMC Palliat Care 2018;17:13. 46. Imai K, Morita T, Mori M, et al. Family experience of pallia- tive sedation therapy: proportional vs. continuous deep seda- tion. Support Care Cancer 2022;30:3903-15. 47. De Araujo C, De Araújo L, Nassar Junior A. Palliative sedation in patients with advanced cancer in a specialized unit in a mid- dle-income country: A retrospective cohort study. Palliative & Supportive Care 2022;20:491-5. 48. Arantzamendi M, Belar A, Payne S, et al. Clinical aspects of palliative sedation in prospective studies. A systematic review. J Pain Symptom Manage 2021;61:831-844.e10. 49. Olsen ML, Swetz KM, Mueller PS. Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clin Proc 2010;85:949-54. Review [page 36] [Emergency Care Journal 2023; 19:11308] Non -co mmerc ial us e o nly