Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care

Symptom Assessment Solutions for In-Home Supportive Services and Diverse Older Adults: A Roadmap for Change

BACKGROUND

Millions of older adults require Medicaid-funded home care, referred to as In-Home Supportive Services (IHSS). Many of these individuals experience serious illness, disability, and common symptoms such as pain and shortness of breath.

OBJECTIVE

To explore whether and how to integrate symptom assessment into an IHSS program to identify and manage symptoms in diverse older adults who receive in-home care.

DESIGN

Qualitative study comprising 10 semistructured focus groups.

SETTING AND SUBJECTS

Fifty San Francisco IHSS administrators, case managers, providers, and consumers.

MEASUREMENTS

Two authors double-coded transcripts and conducted thematic analysis.

RESULTS

Four main themes emerged from the data: (1) Large unmet needs: gaps in understanding, training, standard assessment, and untreated symptoms, including identifying loneliness as a symptom; (2) Potential barriers: misunderstanding of palliative care, consumer reluctance, and the added burden on IHSS workforce; (3) Facilitators: consumer and provider buy-in and perceived benefits of such a symptom assessment program, and the ability to build on current IHSS relationships and infrastructure; and (4) Implementation logistics: taking an individualized, optional approach; consider appropriate messaging about quality of life and not end of life; and creating standardized, easy-to-use procedures, tools, training, and workflow to support providers.

CONCLUSIONS

An IHSS symptom assessment program is desired, needed, and feasible and can leverage the established IHSS infrastructure and relationships of consumers and IHSS providers to assess symptoms in the home. Acknowledging consumer choice, developing appropriate tools and trainings for IHSS staff, and effective messaging of program goals can contribute to success.

Characteristics of Unscheduled and Scheduled Outpatient Palliative Care Clinic Patients at a Comprehensive Cancer Center

CONTEXT

There is limited literature regarding outpatient palliative care and factors associated with unscheduled clinic visits.

OBJECTIVES

To compare characteristics of patients with unscheduled vs. scheduled outpatient palliative care clinic visits.

METHODS

Medical records of 183 unscheduled cancer new outpatients and 104 unscheduled follow-up (FU) patients were compared with random samples of 361 and 314 scheduled new patients and FU patients, respectively. We gathered data on demographics, symptoms, daily opioid usage, and performance status.

RESULTS

Compared with scheduled new patients, unscheduled new patients had worse Edmonton Symptom Assessment Scale subscores for pain (P < 0.001), fatigue (P = 0.002), nausea (P = 0.016), depression (P = 0.003), anxiety (P = 0.038), drowsiness (P = 0.002), sleep (P < 0.001), and overall feeling of well-being (P = 0.001); had a higher morphine equivalent daily dose of opioids (median of 45 mg for unscheduled vs. 30 mg for scheduled; P < 0.001); and were more likely to be from outside the greater Houston area (P < 0.001). Most unscheduled and scheduled new and FU visits were for uncontrolled physical symptoms. Unscheduled FU patients, compared with scheduled FU patients, had worse Edmonton Symptom Assessment Scale subscores for pain (P < 0.001), fatigue (P < 0.001), depression (P = 0.002), anxiety (P = 0.004), drowsiness (P = 0.010), appetite (P = 0.023), sleep (P = 0.022), overall feeling of well-being (P < 0.001), and higher morphine equivalent daily dose of opioid (median of 58 mg for unscheduled FU visits vs. 40 mg for scheduled FU visits; P = 0.054).

CONCLUSION

Unscheduled new FU patients have higher levels of physical and psychosocial distress and higher opioid intake. Outpatient palliative care centers should consider providing opportunities for walk-in visits for timely management and close monitoring of such patients.

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

OBJECTIVES

This study aimed to establish the association between timing and provision of palliative care (PC) and quality of end-of-life care indicators in a population of patients dying of cancer.

SETTING

This study uses linked cancer patient data from the National Cancer Registry, the electronic medical record system used in primary care (SystmOne) and the electronic medical record system used within a specialist regional cancer centre. The population resided in a single city in Northern England.

PARTICIPANTS

Retrospective data from 2479 adult cancer decedents who died between January 2010 and February 2012 were registered with a primary care provider using the SystmOne electronic health record system, and cancer was certified as a cause of death, were included in the study.

RESULTS

Linkage yielded data on 2479 cancer decedents, with 64.5% who received at least one PC event. Decedents who received PC were significantly more likely to die in a hospice (39.4% vs 14.5%, P<0.005) and less likely to die in hospital (23.3% vs 40.1%, P<0.05), and were more likely to receive an opioid (53% vs 25.2%, P<0.001). PC initiated more than 2 weeks before death was associated with avoiding a hospital death (≥2 weeks, P<0.001), more than 4 weeks before death was associated with avoiding emergency hospital admissions and increased access to an opioid (≥4 weeks, P<0.001), and more than 33 weeks before death was associated with avoiding late chemotherapy (≥33 weeks, no chemotherapy P=0.019, chemotherapy over 4 weeks P=0.007).

CONCLUSION

For decedents with advanced cancer, access to PC and longer duration of PC were significantly associated with better end-of-life quality indicators.

EMERALD: Emergency visit audit of patients treated under medical oncology in a tertiary cancer center: Logical steps to decrease the burden

BACKGROUND

We are a tertiary care cancer center and have approximately 1000-1500 emergency visits by cancer patients undergoing treatment under the adult medical oncology unit each month. However, due to the lack of a systematic audit, we are unable to plan steps toward the improvement in quality of emergency services, and hence the audit was planned.

METHODS

All emergency visits under the adult medical oncology department in the month of July 2015 were audited. The cause of visit, the demographic details, cancer details, and chemotherapy status were obtained from the electronic medical records. The emergency visits were classified as avoidable or unavoidable. Descriptive statistics were performed. Reasons for avoidable emergency visits were sought.

RESULTS

Out of 1199 visits, 1168 visits were classifiable. Six hundred and ninety-six visits were classified as unavoidable (59.6%, 95% CI: 56.7-62.4), 386 visits were classified as probably avoidable visit (33.0%, 95% CI: 30.4-35.8) whereas the remaining 86 (7.4%, 95% CI: 6.0-9.01) were classified as absolutely avoidable. Two hundred and ninety-seven visits happened on weekends (25.6%) and 138 visits converted into an inpatient admission (11.9%). The factors associated with avoidable visits were curative intention of treatment (odds ratio - 2.49), discontinued chemotherapy status (risk ratio [RR] - 8.28), and private category file status (RR - 1.89).

CONCLUSION

A proportion of visits to emergency services can be curtailed. Approximately one-fourth of patients are seen on weekends, and only about one-tenth of patients get admitted.

Acute care hospitalization near the end of life for cancer patients who die in hospital in Canada

Acute care hospitals have a role in managing the health care needs of people affected by cancer when they are at the end of life. However, there is a need to provide end-of-life care in other settings, including at home or in hospice, when such settings are more appropriate. Using data from 9 provinces, we examined indicators that describe the current landscape of acute care hospital use at the end of life for patients who died of cancer in hospital in Canada. Interprovincial variation was observed in acute care hospital deaths, length of stay in hospital, readmission to hospital, and intensive care unit use at the end of life. High rates of acute care hospital use near the end of life might suggest that community and home-based end-of-life care might not be suiting patient needs.

mHealth Technologies for Palliative Care Patients at the Interface of In-Patient to Outpatient Care: Protocol of Feasibility Study Aiming to Early Predict Deterioration of Patient's Health Status

Background

Palliative care patients are a particularly vulnerable population and one of the critical phases in patients’ trajectories is discharge from specialized in-patient palliative care into outpatient care, where availability of a palliative care infrastructure is highly variable. A relevant number of potentially avoidable readmissions and emergency visits of palliative patients is observed due to rapid exacerbation of symptoms indicating the need for a closer patient monitoring. In the last years, different mHealth technology applications have been evaluated in many different patient groups.

Objective

The aim of our study is to test feasibility of a remote physical and social tracking system in palliative care patients.

Methods

A feasibility study with explorative, descriptive study design, comprised of 3 work packages. From the wards of the Clinic of Radiation-Oncology at the University Hospital Zurich, including the specialized palliative care ward, 30 patients will be recruited and will receive a mobile phone and a tracking bracelet before discharge. The aim of work package A is to evaluate if severely ill patients accept to be equipped with a tracking bracelet and a mobile phone (by semiquantitative questionnaires and guideline interviews). Work package B evaluates the technical feasibility and quality of the acquired electronic health data. Work package C will demonstrate whether physical activity parameters, such as step count, sleep duration, social activity patterns like making calls, and vital signs (eg, heart rate) do correlate with subjective health data and can serve as indicator to early detect and predict changes in patients’ health status. Activity parameters will be extracted from the mobile phone’s and wristband’s sensor data using signal processing methods. Subjective health data is captured via electronic version of visual analog scale and Distress Thermometer as well as the European Organization for Research and Treatment of Cancer – Quality of Life Questionnaire C30 in paper version.

Results

Enrollment began in February 2017. First study results will be reported in the middle of 2018.

Conclusions

Our project will deliver relevant data on patients’ acceptance of activity and social tracking and test the correlation between subjective symptom assessment and objective activity in the vulnerable population of palliative care patients. The proposed study is meant to be preparatory work for an intervention study to test the effect of wireless monitoring of palliative care patients on symptom control and quality of life.

Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform

Recent payment reforms in health care have spurred thinking regarding how strengthened partnerships can cocreate quality and value. Oncology is an important area in which to consider further collaborations in patient care, as a result of increasing treatment complexity from an expanding armamentarium of interventions, large resource expenditures related to cancer care, and a growing disease prevalence related to an aging population. Many have highlighted the important role of palliative care in the routine care of patients with advanced cancer and high symptom burden. Yet, how integration can occur that translates research into usual clinical practice while prioritizing the right patients and settings to maximize outcomes of interest has been inadequately described. We review the evidence for integration of palliative care into routine oncology care and then map the benefits to the requirements put forward by the Centers for Medicare and Medicaid Services Oncology Care Model as a use case; we also discuss applications to other evolving payment models.

Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center

PURPOSE

Referrals to the Emergency Department can be distressing to patients with advanced cancer and may be a non-optimizing health care service. We aimed to describe the appropriateness and potential avoidability of Emergency Department referrals in a tertiary cancer care center where only physician referrals are allowed.

METHODS

We prospectively reviewed the electronic medical charts of patients consecutively checked into the Emergency Department in August 2015. The appropriateness of referrals was assessed using a nationally validated classification (Classification Clinique des Malades aux Urgences) and local criteria. Potentially avoidable referrals were assessed using international classifications (Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations diagnostic tool according to Kosecoff's criteria) and local criteria.

RESULTS

We included 500 referrals related to 423 patients. The mean age was 59 years, and 74% of cancers were progressive. The referrals were appropriate in 61% of cases. They were deemed potentially avoidable "with a high likelihood" in 33.4% (CI95% [29.3-37.5]) of cases, potentially avoidable "with a moderate likelihood" in 14.4% (CI95% [11.3-17.5]) of cases, and "non-avoidable" in 52% (CI95% [47.6-56.4]) of cases. Opportunities to avoid referrals after an index stay involved this hospital stay or discharge process in 66 cases (28%), the follow-up period in 59 cases (25%), or both in 66 cases (28%).

CONCLUSIONS

Potentially avoidable ED referrals are common in patients with cancer. These potentially avoidable ED referrals underline the importance of several domains of care coordination.

Post-Acute Care Facility as a Discharge Destination for Patients in Need of Palliative Care in Brazil

Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.

Outpatient Palliative Care and Aggressiveness of End-of-Life Care in Patients with Metastatic Colorectal Cancer

Background:

Palliative care in outpatient setting has been shown to promote better symptom management and transition to hospice care among patients with advanced cancer. Nevertheless, specialized palliative care is rarely provided at cancer centers in Korea. Herein, we aimed to assess aggressiveness of end-of-life care for patients with metastatic colorectal cancer according to the use of outpatient palliative care (OPC) at a single cancer center in Korea.

Methods:

We performed a retrospective medical record review for 132 patients with metastatic colorectal cancer who died between 2011 and 2014. Fifty patients used OPC (OPC group), while 82 patients did not (non-OPC group). Indicators of aggressiveness of end-of-life care including chemotherapy use, emergency department visits, hospitalization, and utilization of hospice care were analyzed according to the use of OPC.

Results:

More patients in the OPC group were admitted to hospice than those in the non-OPC group (32% vs 17%, P = .047). The mean of inpatient days within 30 days of death was shorter for the OPC group than the non-OPC group (4.02 days vs 7.77 days, respectively, P = .032). There were no differences in the proportions of patients who received chemotherapy and visited the emergency department within 30 days from death.

Conclusion:

Among patients with metastatic colorectal cancer, OPC was associated with shorter inpatient days near death and greater hospice utilization. Further prospective studies are needed to evaluate the impact of OPC on end-of-life care in Korea.

Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol

REVIEW QUESTIONS/OBJECTIVES

The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?

Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits

BACKGROUND

Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs.

METHODS

In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs.

RESULTS

There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs.

CONCLUSION

Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.

Psychosocial consequences of living with breathlessness due to advanced disease

PURPOSE OF REVIEW

Breathlessness is one of the most important symptoms of patients with advanced life-limiting disease, such as chronic obstructive pulmonary disease, chronic heart failure, cancer, or pulmonary fibrosis. Breathlessness has major implications for patients as well as their family caregivers. The present review provides an overview of recent knowledge concerning the psychological and social consequences of breathlessness, including behavioural responses to breathlessness, and the impact of breathlessness on the family caregiver.

RECENT FINDINGS

Breathlessness results in avoidance of exertion and deterioration of functional status. Functional impairment leads to care dependency and social limitations, resulting in a change in social role. Anxiety is an emotional response to breathlessness, but also increases the perception of breathlessness. Family caregivers of patients have to cope with changes in daily life, witnessing breathlessness and adapt to new and challenging role as family caregiver.

SUMMARY

The consequences of living with breathlessness are multidimensional and arise in all aspects of daily life of patients, their family caregivers and their social environment. Multidimensional treatment programmes should become widely available to support patients with advanced disease and their family caregivers in coping with the functional, psychological and social consequences of living with breathlessness.

Integrating palliative care in oncologic emergency departments: Challenges and opportunities

Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.

ReCAP: Insights Into the Potential Preventability of Oncology Readmissions

QUESTION ADDRESSED:

Are oncology readmissions preventable? If so, what resources and changes in practice or culture would be required to reduce readmissions?

CONCLUSION:

Three independent reviewers analyzed 72 hospital readmissions and found that 22 (31%) of the 72 readmissions were preventable. The most common causes of preventability were overwhelming symptoms in patients who qualified for hospice but were not participating and insufficient communication between patients and the care team about symptom burden. The most common reason for nonpreventability were high symptom burden among patients not appropriate for hospice or for whom aggressive outpatient management was inadequate despite extensive efforts (Table). Readmissions from nursing facilities—where there is little oncology supervision—accounted for 35% of the total.

METHODS:

Standardized criteria to define preventability/nonpreventability were developed before data collection began. The records of sequential nonsurgical readmissions were reviewed independently by two experienced oncology reviewers. When the reviewers disagreed about assignment, a third reviewer broke the tie. Seventy-two readmissions from 69 patients were analyzed. The first two reviewers agreed that 18 (25%) were preventable and that 29 (40%) were not. A third reviewer found four of the split 25 cases to be preventable, so the consensus preventability rate was 22 (31%) of 72.

BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:

A large minority of readmissions can be viewed as a failure of some aspect of the medical care system: symptom management, communication, psychosocial support, education or expectation management. The exact ratio of preventable to nonpreventable readmissions is less important than the finding that many are preventable with better outreach to frail or vulnerable patients and more rigorous or effective goals of care discussions. The findings are consistent with the small number of other studies of readmissions, all judged retrospectively. Such efforts are inherently subjective, but we attempted to minimize bias by creating standard definitions of preventability (Table) and by using independent assessments, avoiding an open consensus process that introduces additional types of bias.

REAL-LIFE IMPLICATIONS:

Some hospital readmissions may be preventable, depending on the conditions and social situation of the patients. Unfortunately, there are no ideal methods for determining preventability of hospital readmissions. Analyses of coded administrative data allow for large data sets, but such methods are silent about the appropriateness or potential preventability of the readmission. Coded data necessarily overlook patient-level issues such as fear, frailty, social isolation or symptom burden, and ignore a patient’s desire for aggressive cancer care. Indeed, some readmissions in oncology are a consequence of continued aggressive therapy that is requested by patients or families and is rendered due to the “shared decision making” process. Chart review, although limiting the sample size, allows more insights into the patient-level and social factors associated with readmissions as well as gaps in the care process, but not all. It cannot determine, for example, if a decision not to opt for hospice care was primarily motivated by patient attitudes, oncologist approach or some combination. Although these data include only 30-day readmissions, the same sort of issue likely pertain to all unplanned admissions and to emergency department visits as well. Oncology programs are encouraged to study their own patterns of unplanned admissions and readmission in order to learn about care gaps. Greater outreach to at–risk patients as in a medical home might prevent many unplanned admissions. Finally, we note that most studies of oncology readmissions have focused on physician assessment of causes with less attention on the patient perspective about reasons for unplanned admission. Such a study is ongoing and will complement these findings. [Table: see text]

Characteristics and outcome of unplanned hospital admissions in patients with lung cancer: a longitudinal tertiary center study. Towards a strategy to reduce the burden

BACKGROUND

Unplanned hospital admissions (UHAs) are frequent in lung cancer, but literature on this topic is scarce. The aim of this study is to gain insight in the demographics, patterns of referral, causes, presenting symptoms, and final outcome of these UHAs. A strategy to improve quality of care and reduce the number and cost of UHAs was suggested based upon these findings.

PATIENTS AND METHODS

In retrospective analysis of all consecutive UHAs in a 6-month period in a tertiary center, demographics, pattern of referral, clinical data, tumor control status, final diagnosis, duration of hospitalization, and outcome were examined.

RESULTS

Two hundred seven UHAs were recorded. Male/female ratio was 185/62, mean age 65.5 years, performance status (PS) on admission 0-1 in 32 %, 2 in 37.2 %, and 3-4 in 30.8 % of patients. Patient referral occurred by general practitioner in 33.6 % or specialist in 25.5 % and in 40.9 % on own initiative. UHAs were therapy-related in 23.9 %, cancer-related in 47.4 %, comorbidity-related in 19.4 %, or of unclear nature in 9.3 %. Most frequent causes were infections (21.9 %) and respiratory problems (17.0 %). Mean length of stay was 9.5 days. Final outcome was 10.1 % mortality, 6.9 % hospice care transfers, and 79.4 % home returns (including 18.2 % same day returns).

CONCLUSION

UHAs in lung cancer were more cancer- than therapy-related. Majority of patients (2/3) were not seen by their general practitioner. A significant number of same day returns were noted. UHAs in patients with poor PS, uncontrolled cancer and cancer-related events had the worst outcome. This work is a first step in identifying specific characteristics of UHAs in lung cancer patients, which may lead to strategies to reduce the burden of UHAs.

Preferred and Actual Location of Death: What Factors Enable a Preferred Home Death?

BACKGROUND

Fulfillment of patient preferences for location of dying is of continued end-of-life care interest. Of those voicing a preference, most prefer home. However the majority of deaths occur in an institutional setting.

OBJECTIVES

The study objective was to report on the congruence between the last preferred and actual location of death among adult Nova Scotians who died from chronic disease, and to identify individual, illness-related, and environmental factors associated with achieving a preferred home death.

METHODS

The study employed a population-based mortality follow-back telephone survey interview. Subjects were eligible death certificate identified informants (next-of-kin) of adults (aged 18+) (n = 1316) who died of advanced chronic diseases in the Canadian province of Nova Scotia between June 2009 and May 2011 who were knowledgeable about the decedent's care over the last month of life. Congruence was assessed as to whether or not the decedent died in their preferred death location. Among decedents preferring a home death, individual, illness-related, and environmental risk factor multivariable analyses were used to identify predictors of home death achievement.

RESULTS

Among all who voiced a preference (n = 606), 52% died in their preferred location (kappa: 0.29). Factors contributing independently to achievement of a preferred home death were emotional needs being met, nursing and family physician home visits, palliative care program involvement, and being at home for the majority of the last month.

CONCLUSIONS

This study identifies elements of primary and integrated care that address the gap between preferred and actual place of care.

Emergency Department Visits at the End of Life of Patients With Terminal Cancer

Frequent emergency department visits (EDVs) by patients with terminal cancer indicates aggressive care. The pattern and causes of EDVs in 154 patients with terminal cancer were investigated. The EDVs that started during working hours and ended by home discharge were considered avoidable. During the last 3 months of life, 77% of patients had at least 1 EDV. In total, 309 EDVs were analyzed. The EDVs occurred out of hour in 67%, extended for an average of 3.6 hours, and ended by hospitalization in 52%. The most common chief complaints were pain (46%), dyspnea (13%), and vomiting (12%). The EDVs were considered avoidable in 19% of the visits. The majority of patients with terminal cancer visit the ED before death, mainly because of uncontrolled symptoms. A significant proportion of EDVs at the end of life is potentially avoidable.

Hospital admission of cancer patients: avoidable practice or necessary care?

BACKGROUND

Cancer patients are frequently admitted to hospital due to acute conditions or refractory symptoms. This occurs through the emergency departments and requires medical oncologists to take an active role. The use of acute-care hospital increases in the last months of life.

PATIENTS AND METHODS

We aimed to describe the admissions to a medical oncology inpatient service within a 16-month period with respect to patients and tumor characteristics, and the outcome of the hospital stay.

RESULTS

672 admissions of 454 patients were analysed. The majority of admissions were urgent (74.1%), and were due to uncontrolled symptoms (79.6%). Among the chief complaints, dyspnoea occurred in 15.7%, pain in 15.2%, and neurological symptoms in 14.5%. The majority of the hospitalizations resulted in discharge to home (60.6%); in 26.5% the patient died and in 11.0% was transferred to a hospice. Admissions due to symptoms correlated with a longer hospital stay and a higher incidence of in-hospital death.

CONCLUSION

We suggest that hospital use is not necessarily a sign of inappropriately aggressive care: inpatient care is probably an unavoidable step in the cancer trajectory. Optimization of inpatient supportive procedures should be a specific task of modern medical oncology.