Neuropalliative Care in the Emergency Department: Three Roles, One Goal.

Over the last decade, there has been an increased focus on incorporating palliative care principles into the practice of neurocritical care and emergency medicine (EM). In this article, we describe three different roles that EM clinicians can fill as they initiate the provision of primary neuropalliative care to neurocritically ill patients: the stage setter, the spokesperson, and the screener. As the stage setter, EM clinicians start to build trust with the family by "breaking bad news"; encouraging them to consider the patient's values, preferences, functional baseline, and directives; and providing support to the family during this emotional time as they hand them over to the admitting team who will continue this conversation. As the spokesperson, EM clinicians are involved in early treatment decisions, including whether the patient is admitted to the acute care service or the intensive care unit or transferred to a tertiary care facility, with the goal of preventing both the overuse and underuse of life-sustaining treatment. Lastly, as the screener, EM clinicians have a role to ensure that patients with chronic neurological diseases and patients with a medical history that puts them at high-risk of developing a neurological emergency have goals-of-care conversations and have acceptable control of their daily symptom burden. Further investigation is needed before interventions targeting the practice of neuropalliative care in the emergency department can be developed.