Palliative Care and Emergency Medicine:
two distinct but integrated networks

FURIO ZUCCO1, COSIMO CHELAZZI2

1Senior Consultant Polis Accademia-Ente di Formazione-Regione Lombardia; Presidente of OdV Presenza Amica per l’aiuto ai sofferenti; 2Associate Professor of Palliative Care, Università di Brescia; Director of SC Cure Palliative e ADI, ASST Spedali Civili di Brescia.

Received on October 19, 2026




The relationship between Emergency Medicine (EM) and Palliative Care (PC) is arousing growing clinical, scientific, and organizational interest, as documented by the increase in publications on the topic1-4, the two contributions in this issue5,6, and the chapter dedicated to EM in PC in the third edition of the ““Libro italiano di medicina e cure palliative” (Italian book of palliative medicine and care)7. This shows a progressive interaction between networks traditionally perceived as distant in the management of time-dependent, complex conditions associated with significant suffering.

PC and EM have long been considered antithetical fields: the former focused on the quality of life of people with incurable diseases in the developmental phase, the latter historically identified with saving and prolonging life. The progressive attenuation of this opposition is also attributable to the increased interest of emergency medicine in end-of-life care and, more specifically, in PC. The inclusion, for the first time in 2018, of a chapter on CP in Tintinalli’s Emergency Medicine Manual, one of the most widely used EM manuals at international level, goes in this direction.

The evolution of medicine redefines the meaning of “limit” and the concepts of proportionality and futility in the advanced stages of oncological and non-oncological diseases. The increasingly less invasive devices for the support of vital respiratory, cardiocirculatory, renal and metabolic functions thus induce us to reconsider the “low tech, high touch” principle, of which Cicely Sauders is the philosophical mother and John Naisbitt the lexical father8. For PC teams, a new formulation “best tech for high touch”, summarises a selective use of technology, aimed at supporting the care relationship, symptom control and the appropriateness of interventions. The use of continuous infusion systems in Palliative sedation has extended beyond hospices and homes. During the Covid-19 pandemic, end-of-life management in Emergency Departments, high-intensity departments and Nursing homes and Residential Healthcare Facilities has also involved non-specialist teams in the use of these technologies. Consistently, the 2023 SICP-SIAARTI Guidelines on Palliative sedation in adults are aimed at all contexts in which refractory symptoms or signs are present, including emergencies9. In critical and EM contexts, in-hospital PC can therefore contribute to end-of-life support, the assessment of proportionality, symptom control, communication and the definition of care objectives.

A first area of integration concerns people hospitalized in critical care or EM settings whose need for PC is already present, but not yet recognized or addressed by specialist networks. Emergency Rooms and Emergency Departments can be places for identifying complex needs: symptomatic suffering, advanced frailty, limited prognosis, repeated hospital admissions, uncertainty about treatment goals. Recognition of the need for palliation can be followed by the activation of PC Unit in the hospital setting, integrating clinical assessment, symptom management, communication with the individual and family, and liaison with the community network, in order to promote continuity after the acute phase. In this context, emergency and urgency take on a somewhat broader meaning in PC than is commonly used in clinical settings. In the traditional sense, “emergency” refers to an ongoing life-threatening condition, while “urgency” refers to a potentially life-threatening condition. In PC, the timeliness of intervention is also correlated with the possibility of reducing intense and potentially avoidable suffering. In non-terminal dyspneic crisis, sudden worsening of pain, pathological fractures, or acute bladder distention, delaying treatment can lead to prolonged suffering7.

The relationship between EM and PC includes, in addition to a timely, non-futile diagnostic and therapeutic response, the definition of care objectives. In critical settings, palliative counseling can help distinguish reversible interventions consistent with the patient’s goals from disproportionate ones and support shared decisions, limiting the non-selective use of therapeutic escalation. For patients not yet included in PC pathways, access to EM can represent an opportunity to recognize the need and initiate appropriate care.

A second area concerns urgencies and emergencies that arise during an already initiated PC pathway. PC consider events that can lead to death within hours – hemorrhages, mediastinal syndromes, intestinal obstruction, electrolyte alterations – and sudden symptomatic exacerbations or “breakthroughs”7. Knowledge of these conditions allows us to evaluate the proportionality of any etiopathogenic treatment and to prepare timely responses geared towards the patient’s quality of life and the support of the family unit, caregiver, and volunteers who assist them. Even less severe clinical problems, such as the leakage of a subcutaneous cannula, can lead to critical care issues and require extemporaneous access to the healthcare or social healthcare network.

The management of such events can be based on an anticipatory and structured approach. Shared care planning can take into account acute crises, specifying objectives, adequate interventions, contact persons, activation criteria, and locations of care. In the absence of a qualified and continuous response, the sudden onset or worsening of serious symptoms and signs in a vulnerable person frequently leads to the activation of the local emergency medical service network, by calling the European single emergency number 112 and transporting them to the nearest ER. The importance of the emergency is also recognized by Italian national law 219/2017. Article 1, paragraph 7, requires the doctor and the team to ensure the necessary care in compliance with the patient’s wishes, when conditions allow for this; article 4, paragraph 6, instead regulates the verbal revocation of advance treatment directives when emergency and urgency reasons prevent the use of ordinary forms. In time-dependent contexts, informed consent, advance directives, and shared care planning therefore confirm the importance of a structured interaction between the two networks.

A further development consists in considering that access to emergency medical services does not necessarily represent a negative outcome of PC. In early or simultaneous PC pathways, the illness trajectory may include acute events amenable to treatment, urgent assessments, or technological interventions consistent with shared objectives. Even a person already in the PC network’s care can therefore access 112, the Emergency Rooms, or an Emergency Department in an appropriate, consistent, and, at least, partially, predictable manner. The focus is therefore on the proportionality of access, the expected benefit, and the continuity of previously shared decisions throughout the care pathway.

The possibility of planning access to EM services is part of a broader evaluation of the use of technologies throughout the entire disease trajectory: before PC, during the treatment program, and in the acute phases. Examples include the deactivation of pacemakers and implantable defibrillators in hospices or at home10 and the management of errors or malfunctions in devices used for symptom control11. In each of these situations, the evaluation considers the intervention’s consistency with the treatment objectives, non futility and contribution to maintaining the relationship and managing suffering, in addition to the care setting.

Integration between PC and Emergency teams can be supported by shared operating methods. The specialized PC network, particularly the home-based one, should operate 24 hours a day, 365 days a year, according to a continuity standard similar to that of the extra- and intra-hospital Emergency network. A special case is that of the Lombardy Region: since 2016, it has progressively guaranteed this standard of provision to 10 million residents. A specific Regional Council Resolution has made it mandatory for each public or private institution accredited for palliative home care (UCP-Dom) to have a palliative care team of medical and nursing staff available 24/7 for all patients cared for by the team, both at the basic palliative home care level and at the palliative specialist level.

Useful tools include criteria for the early recognition of PC needs in critical settings, timely access to in-hospital PC, and advance crisis management plans12,13. These are supported by direct communication channels, including telemedicine, procedures that define responsibilities, activation criteria, and response times, as well as joint training activities and practice-oriented research. The process may also take into consideration the structures and figures introduced in 2022 by Ministerial Decree 77, including Territorial coordination hub for primary car continuity, Community Hospitals and Family and Community Nurses.

Dialogue between the two networks can extend beyond the management of individual events, contributing to the definition of pathways in which palliative care needs are recognized in EM, emergencies for patients already in care are addressed according to shared plans, and access to emergency services remains available when consistent with the disease trajectory. The transition from separate to integrated networks can thus foster timely, appropriate responses that respect the wishes, dignity, and suffering of the patient.

References

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