Introduction of Hospice Care Model in the Emergency Department to Optimize the End of Life Journey for Patients

Having passed its third reading at the end of 2015, the Patient Right to Autonomy Act is the first special law of its kind in Asia and will come into force next year in Taiwan. Taiwan is one of the first Asian countries to develop a law relating to the protection of the patient right to autonomy after such laws have already seen enactment in the US, Great Britain, Australia, and several European countries. The Well-Dying Law passed in South Korea last August only applies to terminally ill patients, while in Japan, such topics are still in the proposal stage. The Patient Right to Autonomy Act in Taiwan allows a person with legal capacity to appoint a health care power of attorney in advance who can choose to accept or reject life-sustaining treatment or artificial nutrition and hydration under 5 clinical conditions through Advance Care Planning (ACP) and Advance Decision (AD). The five clinical conditions are terminal illnesses, irreversible coma, very severe dementia, permanent vegetative state, and other critical illnesses announced by government. The Act is seen as an important milestone in advancing the right to a "good end."

Also dedicated to promoting the "good end" is Chi Mei Hospital, the first in Taiwan to set up emergency department (ED) hospice care, an innovative aggressive medical practice that is rarely seen in the world. The ED is where an intensive tug-of-war with death occurs where every second is vital. Factors such as the rapidly changing state of critical conditions and the emotionally charged family members often lead to medical disputes and violence in the ED. In response, Chi Mei Hospital established the holistic care division to bring hospice care from the ward to the frontline - the emergency observation unit. And because it has seen how helpless end-of-life patients are while waiting for a bed in the emergency department, Chi Mei Hospital organized an ED hospice care team, spearheaded by Doctor Tzu-Chieh Weng, an attending doctor in the holistic care division who personally went through a near-death experience. "During the near-death experience, I experienced enormous fear and helplessness, and was worried about my family, so I wanted to do something for those who are still alive. Promoting emergency department hospice care, that is my agreement with Death" says Weng of his realization and newfound mission after he suffered aortic dissection and was wrestled free from the grips of Death through surgery.

Several factors impede the implementation of ED hospice care. Firstly, emergency doctors are extremely busy, and often do not have the time to establish a good doctor-patient relationship and discuss the issue of life and death. Secondly, family members may mistakenly interpret hospice care as giving up treatment. Other factors include the different standards that different doctors have in determining what constitutes as "terminal," and the inability for family members to accept hospice care. To this end, Chi Mei Hospital has dedicated an entire unit to overcome the difficulties one by one by achieving the following:

1. Establishing a dedicated team (including doctors, nursing staff, social workers, psychologists, and chaplain)
2. Training the attending physician in the hospice and palliative care specialty
3. Being the first to train emergency department residents in hospice and palliative care
4. Requiring residents to rotate through the hospice to help them gain empathy and understand the care and end-of-life needs of terminally ill patients
5. Hosting family meetings with the terminally ill patient and their family members
6. Adding a "terminal" category to the triage to identify terminally ill patients for early hospice intervention
7. Allocating an independent hospice space in the crowded emergency department to allow the patient and their family members to say goodbye in peace

However, the general public is still very unfamiliar with hospice care. Therefore, Chi Mei Hospital has again led the country in introducing an interactive touch-controlled computer game and VR experience. The public can experience through the end of life, including disease, aging, emergency, being bedridden, intubation, CPR, and home hospice care. The experience was so true-to-life that almost everyone was in tears after participating. 77% of the public said that they do not wish to receive life sustaining treatment before they die; they want to leave the world with dignity.

Shifting the discussion from the patient side to the hospital side, what does the hospital have to gain in promoting ED hospice care?

"Reform medical costs, reduce medical disputes, avoid futile medical care," says Chi Mei Hospital's Dr. Wan-Ting Hsieh. Since ED hospice care moves communication to the front of the process, the patient and their family members have more time to understand the medical circumstances and the possible measures to be taken. Such a move can avoid the controversy that may occur if the patient's condition quickly deteriorates or in case of poor communication. The emergency staff can then focus on what's beneficial for the patient, protecting and improving the quality of medical care for the patient.

When people hear the word "hospice," their first impression may be "a place where the staff does nothing and waits for the patient to die." However, the true meaning of hospice is to allow the end-of-life patient and their family members to accept their journey at the end of life. Hospice provides for the patient care for the physical, psychological, and spiritual problems, so they can take a peaceful final journey in life with dignity. Family members are encouraged to provide company and care, so solace is achieved in life and in death. Chi Mei Hospital accounts for the largest proportion of home hospice care service in Taiwan and has continued to improve its quality. The home hospice care service has received positive response from the family members, and its achievements have been reported in the media. Their spirit of "finite care with infinite love" is truly moving.

*Chi Mei Hospital's Emergency Department Hospice Care Team and Palliative Care Center have received Taiwan's Symbol of National Quality certification review with "Accompany the last mile of the dignity of life: a hospice team at Chi Mei ER" and "Finite care with infinite love: Bridging palliative care with multi discipline"
 
(Editing by Nicole Yang, Research Center for Biotechnology and Medicine Policy)

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