United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department

Evaluation of the Acute Basic Palliation Concept by Relatives and Health Care Professionals: An Observational Study of 40 Home-Dying Patients in Denmark

Background: Many individuals prefer to pass away in the comfort of their own homes, yet logistical obstacles often result in their admission to hospitals for end-of-life care. Objectives: To measure the effectiveness, as assessed by relatives and staff, of end-of-life care according to the acute basic palliation concept (ABPC) for patients discharged from an emergency department. Methods: An observational study of 40 consecutive actively dying patients who were discharged from Aalborg University Hospital, Denmark, using the ABPC. Effectiveness of end-of-life care was measured by questionnaires to relatives, discharging doctors and nurses, and municipality health staff. The ABPC comprised a physician checklist, instructions for medical professionals, a medication template to be personalized, an added standardized text to discharge papers, information pamphlets for patients and relatives, and a box of medicine and utensils. Results: Among the 40 included patients (mean age 84, standard deviation [SD] 7.7), four experienced improvements at home and resumed active treatment. The patients who died had an average survival time of 3.8 days (SD 7.5). According to relatives, 90% of patients died a dignified death without suffering. Municipality nurses rated the usefulness of the ABPC at 96 (interquartile range 88; 100) on a 0-100 scale, and all health care staff wanted to use the ABPC again. Conclusion: The ABPC showed great potential as a tool for discharging dying patients without specialized palliative needs to good-quality end-of-life care at home. The ABPC was widely accepted by relatives and all health staff. The ABCP is ready for large-scale testing with patient subgroups and economic analysis.

[The older patient in intensive care]

Demographic trends mean that the proportion of older and very old patients in hospitals at all levels of care is increasing. This means that significantly more patients from these age groups can be expected in the future. These developments pose new challenges for both medical care and the management of geriatric intensive care patients, taking into account their multimorbidity and functional limitations due to acute illness. Although mortality increases with age, the outcome is highly dependent on the patient's functionality and comorbidity. The elderly patient also shows structural and functional organ changes, knowledge of which is important for the treatment of geriatric patients in intensive care medicine. This increasing need for geriatric treatment will have a decisive influence on the development of intensive care medicine in the coming years.

Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program

INTRODUCTION

80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice.

METHODS

We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS).

RESULTS

202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21).

CONCLUSION

In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.

Accuracy of the "Surprise Question" in Predicting Long-Term Mortality Among Older Patients Admitted to the Emergency Department: Comparison Between Emergency Physicians and Nurses in a Multicenter Longitudinal Study

Background

The "surprise question" (SQ) ("Would you be surprised if this patient died in the next 12 months?") is the most frequently used screening tool in emergency departments (EDs) to identify patients with poor prognosis and potential unmet palliative needs.

Objective

To test and compare the accuracy of the SQ between emergency nurses (ENs) and emergency physicians (EPs) in predicting long-term mortality among older patients (OP) in the ED.

Design and Setting/Subjects

A prospective cohort study of OPs (≥75 years) conducted in two Belgian EDs. EPs and ENs answered the SQ for the patients they cared for. Positive SQ (SQ+) was defined as a "no" answer. One-year mortality was assessed by phone call.

Results

EPs and ENs both answered the SQ for 291 OPs (mean age 83.2 ± 5.4, males 42.6%). The SQ was positive in 43% and 40.6%, respectively. Predictive values were similar in both groups: sensitivity, specificity, c-statistics, negative predictive value, and positive predictive value were 0.79 (0.66-0.88), 0.68 (0.62-0.76), 0.69 (0.63-0.75), 0.92 (0.86-0.96), and 0.4 (0.31-0.50), respectively, for EPs and 0.71 (0.57-0.82), 0.69 (0.62-0.75), 0.69 (0.63-0.75), 0.89 (0.83-0.93), and 0.41 (0.31-0.51), respectively, for ENs. SQ + was associated with a higher mortality risk in both group (EPs hazard ratio: 3.2 [1.6-6.7], p = 0.002; ENs hazard ratio: 2.5 [1.3-4.8], p = 0.006). The survival probability was lower when both EPs and ENs agreed on the SQ+ (p < 0.001).

Conclusion

The SQ is a simple tool to identify older ED patients at high mortality risk. Concordant responses from EPs and ENs are more predictive than either alone.

Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission

BACKGROUND

Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population.

METHODS

We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis.

RESULTS

Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile.

CONCLUSIONS

Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.

Multi-organ Thromboembolic Crisis: A Case Report of Concomitant Stroke, Myocardial Infarction, and Pulmonary Embolism

Management of acute coronary syndrome (ACS), cerebrovascular accident (CVA), and pulmonary embolism (PE) necessitates prompt intervention, as delayed treatment may lead to severe consequences. Each of these conditions presents significant challenges and carries a high risk of morbidity and mortality. We present the case of an 86-year-old female with a history of stage 4 urothelial carcinoma metastasized to the lungs, who presented to the emergency department (ED) with acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), and bilateral PE. We propose the term "multi-organ thromboembolic crisis" (MOTEC) to streamline the communication and management approach for patients experiencing critical thromboembolic events affecting multiple organ systems.

The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand

BACKGROUND

Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people.

OBJECTIVES

To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere.

METHODS

We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression.

RESULTS

From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation.

CONCLUSIONS

Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

Emergency department hospice care pathway associated with decreased ED and hospital length of stay

INTRODUCTION

While increasing evidence shows that hospice and palliative care interventions in the ED can benefit patients and systems, little exists on the feasibility and effectiveness of identifying patients in the ED who might benefit from hospice care. Our aim was to evaluate the effect of a clinical care pathway on the identification of patients who would benefit from hospice in an academic medical center ED setting.

METHODS

We instituted a clinical pathway for ED patients with potential need for or already enrolled in hospice. This pathway was digitally embedded in the electronic health record and made available to ED physicians, APPs and staff in a non-interruptive fashion. Patient and visit characteristics were evaluated for the six months before (05/04/2021-10/4/2021) and after (10/5/2021-05/04/2022) implementation.

RESULTS

After pathway implementation, more patients were identified as appropriate for hospice and ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 h. Social work consultation for hospice evaluation increased, and more patients were discharged from the ED with hospice. As more patients were identified with end-of-life care needs, the number of patients admitted to the hospital increased. However, more patients were admitted under observation status, and admission LOS decreased by a median of 18.4 h.

CONCLUSION

This non-interruptive, digitally embedded clinical care pathway provided guidance for ED physicians and APPs to initiate hospice referrals. More patients received social work consultation and were identified as hospice eligible. Those patients admitted to the hospital had a decrease in both ED and hospital admission LOS.

[Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]

The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

Automatable end-of-life screening for older adults in the emergency department using electronic health records

BACKGROUND

Emergency department (ED) visits are common at the end-of-life, but the identification of patients with life-limiting illness remains a key challenge in providing timely and resource-sensitive advance care planning (ACP) and palliative care services. To date, there are no validated, automatable instruments for ED end-of-life screening. Here, we developed a novel electronic health record (EHR) prognostic model to screen older ED patients at high risk for 6-month mortality and compare its performance to validated comorbidity indices.

METHODS

This was a retrospective, observational cohort study of ED visits from adults aged ≥65 years who visited any of 9 EDs across a large regional health system between 2014 and 2019. Multivariable logistic regression that included clinical and demographic variables, vital signs, and laboratory data was used to develop a 6-month mortality predictive model-the Geriatric End-of-life Screening Tool (GEST) using five-fold cross-validation on data from 8 EDs. Performance was compared to the Charlson and Elixhauser comorbidity indices using area under the receiver-operating characteristic curve (AUROC), calibration, and decision curve analyses. Reproducibility was tested against data from the remaining independent ED within the health system. We then used GEST to investigate rates of ACP documentation availability and code status orders in the EHR across risk strata.

RESULTS

A total of 431,179 encounters by 123,128 adults were included in this study with a 6-month mortality rate of 12.2%. Charlson (AUROC (95% CI): 0.65 (0.64-0.69)) and Elixhauser indices (0.69 (0.68-0.70)) were outperformed by GEST (0.82 (0.82-0.83)). GEST displayed robust performance across demographic subgroups and in our independent validation site. Among patients with a greater than 30% mortality risk using GEST, only 5.0% had ACP documentation; 79.0% had a code status previously ordered, of which 70.7% were full code. In decision curve analysis, GEST provided greater net benefit than the Charlson and Elixhauser scores.

CONCLUSIONS

Prognostic models using EHR data robustly identify high mortality risk older adults in the ED for whom code status, ACP, or palliative care interventions may be of benefit. Although all tested methods identified patients approaching the end-of-life, GEST was most performant. These tools may enable resource-sensitive end-of-life screening in the ED.

Emergency Department Clinician Experience with Embedded Palliative Care

Background: While the benefits of embedding palliative care (PC) clinicians into the emergency department (ED) are now more widely appreciated, only a handful of programs have been reported in the literature. None has previously evaluated the attitudes and experiences of the multidisciplinary ED team with such an intervention. Objectives: We evaluated the experience of ED attendings, residents, nurses, social workers, and chaplains with an embedded PC clinician in the ED. Design/Subjects: We embedded PC clinicians into an urban, academic ED in the United States and surveyed 142 ED clinicians about their experiences. We analyzed survey results using descriptive analysis for closed-ended responses and thematic analyses for open-ended responses. Measurements/Results: One hundred six of 141 clinicians responded (75% response rate). Quantitative analysis found that 99% of participants found the program valuable. Benefits of embedded PC included changing patients' management or care trajectory, freeing up ED providers for other tasks, contributing to provider education, helping providers feel more supported during their shifts, and adding to providers' skill sets and confidence in practicing primary PC. Most participants reported minimal barriers to engaging with PC. The qualitative analysis identified program approval, desire for expansion/continuation of the program, and ongoing education of ED staff. Important themes for future programs include staff education, PC proactivity, importance of adapting to the needs of the ED, and education regarding PC consultation criteria. Conclusions: ED clinicians' attitudes toward embedded PC reflected overall approval, with underlying themes of providers feeling more supported during their shifts, improved resource management, the perception of better patient care, and nursing empowerment.

Top Ten Tips Palliative Care Clinicians Should Know About Improving Partnerships with Emergency Medical Services

Emergency medical services (EMS) clinicians increasingly encounter seriously ill patients and their caregivers in times of distress. When crises arise or care coordination falls short, these high-stakes interactions highlight opportunities to improve care experience and outcomes. Efforts must address wide educational gaps, absence of specialized care protocols, and systematic fragmentation leading to hyperlocal practice. The authors represent cross-sectional expertise in palliative care and EMS. This article describes unmet needs at the EMS-palliative interface, challenges with collaboration, and where directional progress exists.

Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

CONTEXT

During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training.

OBJECTIVES

To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training.

METHODS

A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals.

RESULTS

Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups.

CONCLUSION

Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.

Primary Palliative Care in the Emergency Department and Acute Care Setting

Amidst a global COVID pandemic, the palliative care community and healthcare systems around the country continue to explore opportunities to improve early patient and family access to end-of-life care resources. They need not look any further than the Emergency Departments (ED) located on their campuses and around their communities for this chance. As advances in medical therapies continue to extend disease specific life expectancies and as the American population continues to age, we will continue to see older adults with chronic medical illnesses visiting the ED in their final stages of life (Smith et al. in Health Aff (Millwood) 31(6):1277-1285, 2012; Albert et al. in NCHS Data Brief 130:1-8, 2013). If the ED is to continue to be the primary portal of hospital entry for patients requiring emergent care for acute and chronic terminal illnesses, then it stands to reason that it should also be equally prepared to provide the earliest access to palliative care and advance care planning resources for patients and families who may want and benefit from these services. This chapter will explore the unique horizon of opportunities that exist for emergency medicine and the palliative care specialty to fulfill this obligation. Discussion will be centered around core principles in screening, assessment, and management of palliative care needs in the ED, importance of goals of care conversations, and the coordination of early palliative care and hospice consults that can facilitate safe transitions of care.

Developing a novel integrated geriatric palliative care consultation program for the emergency department

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.

Emergency Department Embedded Palliative Care Service Creates Value for Health Systems

Background: Emergency department (ED)-initiated palliative care consultation facilitates goal-concordant care while stewarding resource utilization. Delivery models are being piloted without clear operational and financial sustainability. Objective: To demonstrate that embedding a palliative care consultation service in the ED is clinically meaningful, operationally viable, and yields significant return on investment (ROI). Methods: Quasi-experimental study from August 17, 2020 to August 17, 2021. We established an ED-embedded palliative care consultation service at a 350-bed urban community hospital with 45,000 annual ED visits. A singe palliative care provider stationed in the main ED workstation area from 11 am to 7 pm daily. Matched analysis compared ED-embedded consultations against Floor and intensive care unit (ICU) consultations originating from usual practice. Results: ED consultations increased 10x, without cannibalization, to become the hospital's primary source of palliative care consultations. Clinical outcomes were meaningful, with 49% changing code status, 11% admitting to lower level of care, 11% avoiding hospitalization, 17% newly referred to hospice, and 21% newly referred to palliative care clinic. ED length of stay (LOS) did not lengthen, and ED staff strongly agreed that the service was valuable and unobtrusive. Compared with Floor, ED consultations had 8.1 days shorter hospital LOS (3.0 vs. 11.1 days, p < 0.01) with $5,974 lower median direct costs for index hospitalization ($6,211 vs. $12,005, p < 0.01). Compared with ICU, ED consultations had 4.2 days shorter hospital LOS (3.0 vs. 7.2 days, p < 0.01) with $9,332 lower median direct costs for index hospitalization ($14,093 vs. $23,425, p < 0.01). ROI was 6.7x net of foregone revenue and labor expenses. Conclusions and Relevance: This ED-embedded palliative care consultation service was clinically meaningful, operationally viable, and delivered a 6.7x ROI. ED-palliative partnerships present a quadruple aim opportunity to improve care for seriously ill patients.