Characteristics of emergency department patients who receive a palliative care consultation

Palliative care patient emergency department visits at tertiary university-based emergency department in Ireland

INTRODUCTION

Palliative care patients often present to the emergency department (ED) for various reasons e.g., acute illness, pain, altered mental status, and complications of therapy. Many visits involve less severe etiologies e.g., dyspnea, constipation, fear as patients approach the end of life, which may be more effectively and efficiently managed outside of the ED. The objective of this study is to identify and assess the frequency of presenting complaints, primary diagnosis, triage acuity, need for admission, in an Irish setting.

METHODS

A single-center retrospective, observational study of palliative care patients presenting to a tertiary-care university hospital emergency department in Dublin, Ireland. Study subjects were identified using the palliative care database and cross-referencing with the ED electronic patient record system database. The primary objective to identify potential areas to minimize ED visits and improve patient care and quality of life by elucidating reasons for visits. Outcome measures include presenting complaint, primary diagnosis, triage severity score, admission, discharge, death in hospital. Statistical analysis presented as descriptive statistics.

RESULTS

Four-hundred-ninety-nine ED visits, 245 (49%) were male, and 254 (51%) were female with a mean age of 69.3 years-of-age. Most patients, 285 (57.1%) self-referred to the emergency department, with general practitioners and skilled nursing facility referrals 72 (14.4%) and 39 (7.8%), respectively. Primary diagnoses were various cancers, chronic obstructive pulmonary disease, congestive heart failure, and dementia. Major reasons for visits were dyspnea, pain, falls, trauma, fever, and altered mental status. Two-hundred-eighty-nine patients (58%) had an emergency severity index (ESI) score of 1 or 2 demonstrating a higher level of acuity. Three-hundred-fifty-eight (71.7%) were admitted, 141 (28.3%) discharged to home, 64 (12.8%) admitted patients died during their hospital admission.

CONCLUSIONS

Palliative care patients utilize ED services not uncommonly. Though many of these patients presented with higher acuity triage scores, 42% had lower ESI scores and may be effectively managed outside of the ED. These data suggest developing mechanisms for these patients to be urgently evaluated in their homes or facilities obviating the need for an ED evaluation.

Advance Care Planning Among Patients With Advanced Illness Presenting to the Emergency Department

BACKGROUND

Advance care planning (ACP) benefits emergency department (ED) patients with advanced illness. Although Medicare implemented physician reimbursement for ACP discussions in 2016, early studies found limited uptake.

OBJECTIVE

We conducted a pilot study to assess ACP documentation and billing to inform the development of ED-based interventions to increase ACP.

METHODS

We conducted a retrospective chart review to quantify the proportion of ED patients with advanced illness with Physician Orders for Life-Sustaining Treatment (POLST) or coding of ACP discussion in the medical record. We surveyed a subset of patients via phone to evaluate ACP participation.

RESULTS

Of 186 patients included in the chart review, 68 (37%) had a POLST and none had ACP discussions billed. Of 50 patients surveyed, 18 (36%) recalled prior ACP discussions.

CONCLUSIONS

Given the low uptake of ACP discussions in ED patients with advanced illness, the ED may be an underused setting for interventions to increase ACP discussions and documentation.

Mapping the future for research in emergency medicine palliative care: A research roadmap

BACKGROUND

The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.

OBJECTIVE

The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.

METHODS

Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.

RESULTS

Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.

CONCLUSIONS

There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Causes for Emergency Hospitalization of Neurological Patients With Palliative Care Needs

Background: Acute and unexpected hospitalization can cause serious distress, particularly in patients with palliative care needs. Nevertheless, the majority of neurological inpatients receiving palliative care are admitted via an emergency department.

Objective: Identification of potentially avoidable causes leading to acute hospitalization of patients with neurological disorders or neurological symptoms requiring palliative care.

Methods: Retrospective analysis of medical records of all patients who were admitted via the emergency department and received palliative care in a neurological ward later on (n = 130).

Results: The main reasons for acute admission were epileptic seizures (22%), gait disorders (22%), disturbance of consciousness (20%), pain (17%), nutritional problems (17%), or paresis (14%). Possible therapy limitations, (non)existence of a patient decree, or healthcare proxy was documented in only 31%. Primary diagnoses were neoplastic (49%), neurodegenerative (30%), or cerebrovascular (18%) diseases. Fifty-nine percent were directly admitted to a neurological ward; 25% needed intensive care. On average, it took 24 h until the palliative care team was involved. In contrast to initially documented problems, key challenges identified by palliative care assessment were psychosocial problems. For 40% of all cases, a specialized palliative care could be organized.

Conclusion: Admissions were mainly triggered by acute events. Documentation of the palliative situation and treatment limitations may help to prevent unnecessary hospitalization. Although patients present with a complex symptom burden, emergency department assessment is not able to fully address multidimensionality, especially concerning psychosocial problems. Prospective investigations should develop short screening tools to identify palliative care needs of neurological patients already in the emergency department.

An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study

Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ² tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.

Palliative Care and Rapid Emergency Screening Tool and the Palliative Performance Scale to Predict Survival of Older Adults Admitted to the Hospital From the Emergency Department

BACKGROUND

The Palliative Care and Rapid Emergency Screening (P-CaRES) tool has been validated to identify patients in the emergency department (ED) with unmet palliative care needs, but no prognostic data have been published. The Palliative Performance Scale (PPS) has been validated to predict survival based on performance status and separately has been shown to predict survival among adults admitted to the hospital from the ED.

OBJECTIVE

To concurrently validate the 6-month prognostic utility of P-CaRES with a replication of prior studies that demonstrated the prognostic utility of the PPS among adults admitted to the hospital from the ED.

DESIGN

Prospective cohort study.

SETTING/SUBJECTS

Adults >55 years admitted to the hospital from the ED at an urban academic hospital in South Carolina.

MEASUREMENT

Baseline PPS score and P-CaRES status were evaluated within 51 hours of admission. Vital status at 6 months was evaluated by phone or chart review.

RESULTS

131 of 145 participants completed the study. Six-month survival was 79.2% of those with a PPS of 60-100 (22/106 died) and 48% of those with a PPS of 10-50 (13/25 died) (p = 0.0004). Six-month survival was 85.2% for P-CaRES negative (13/88 died) and 48.8% for P-CaRES positive (22/43 died) (p < 0.0001). The inferred hazard ratio (HR) for PPS 10-50, as compared to PPS 60-100 was 3.003 (95%CI (1.475, 6.112) p = 0.0024) and the HR for P-CaRES positive, as compared to P-CaRES negative was 4.186 (95%CI (2.052, 8.536) p < 0.0001).

CONCLUSION

The P-CaRES tool and PPS can predict 6-month survival of older adults admitted from the ED.

Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit

BACKGROUND

Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU).

METHODS

We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization.

RESULTS

A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05).

CONCLUSION

Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.

A quasi-experimental evaluation of an intervention to increase palliative medicine referral in the emergency department

Objective

To evaluate a new intervention intended to increase referral rates from the emergency department (ED) to the palliative medicine service (PMS) in acute hospitals.

Methods

We conducted a quasi-experimental evaluation in an urban teaching hospital in Dublin, Ireland. Data were collected over two eight-week periods in November/December 2013 and May/June 2015, with the PALliative Medicine in the Emergency Department (PAL.M.ED.™) intervention implemented in the intervening period. All adults who were admitted to the hospital via the ED during the two time periods and who received a palliative care consultation during their hospital stay were included in the study. Our primary analysis evaluated the impact of PAL.M.ED.™ on PMS referral in the ED. Our secondary analysis evaluated the impact of PMS referral in the ED on length of stay (LOS) and utilization, compared to PMS referral later in the admission. We controlled for observed confounding between groups using propensity scores.

Results

PAL.M.ED.™ was associated with an increase in PMS referral in the ED ( p < 0.005; odds ratio: 10.5 (95%CI: 3.8 to 28.7)). PMS referral in the ED was associated with shorter hospital LOS ( p < 0.005; −10.9 days (95%CI: −17.7 to −4.1)).

Conclusions

Low PMS referral rates in the ED, and the poor outcomes for patients and hospitals that arise from admissions of those with serious illness, may be mitigated by a proactive intervention to identify appropriate patients at admission.

The Surprise Question Can Be Used to Identify Heart Failure Patients in the Emergency Department Who Would Benefit From Palliative Care

CONTEXT

Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The "surprise question" (SQ) "Would you be surprised if this patient died in the next 12 months?" is a simple tool to identify patients at risk for 12-month mortality.

OBJECTIVES

The objective of this study was to assess the accuracy of the SQ when used by EPs to assess patients with HF.

METHODS

We conducted a prospective cohort study in which clinicians applied the SQ to patients presenting to the ED with symptoms of HF. Chart review and review of death records were completed. The primary outcome was accuracy of the surprise question to predict 12-month mortality. A univariate analysis for potential predictors of 12-month mortality was performed.

RESULTS

During the study period, 199 patients were identified, and complete data were available for 97% of observations (n = 193). The one-year mortality was 29%. EPs reported that "they would not be surprised" if the patient died within the next 12 months in 53% of cases. 42.7% of these patients died within 12 months compared to 13.3% in the "would be surprised" group. There was a strong association with death in the "not surprised" group (odds ratio 4.85, 95% CI 2.34-9.98, P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of the SQ were 78.6%, 56.9%, 42.7%, and 86.7%, respectively, with c-statistic = 0.68.

CONCLUSION

The SQ screening tool can assist ED providers in identifying HF patients that would benefit from early palliative care involvement.

“Better pathways of Care”: Suggested Improvements to the Emergency Department management of People with Advanced Cancer

Objective: It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions. Methods: This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semi-structured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care. Results: Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education. Conclusion: The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

A systematic review of the use of the electronic health record for patient identification, communication, and clinical support in palliative care

Objectives

Globally, healthcare systems are using the electronic health record (EHR) and elements of clinical decision support (CDS) to facilitate palliative care (PC). Examination of published results is needed to determine if the EHR is successfully supporting the multidisciplinary nature and complexity of PC by identifying applications, methodology, outcomes, and barriers of active incorporation of the EHR in PC clinical workflow.

Methods

A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The data sources PubMed, CINAL, EBSCOhost, and Academic Search Premier were used to identify literature published 1999–2017 of human subject peer-reviewed articles in English containing original research about the EHR and PC.

Results

The search returned 433 articles, 30 of which met inclusion criteria. Most studies were feasibility studies or retrospective cohort analyses; one study incorporated prospective longitudinal mixed methods. Twenty-three of 30 (77%) were published after 2014. The review identified five major areas in which the EHR is used to support PC. Studies focused on CDS to: identify individuals who could benefit from PC; electronic advanced care planning (ACP) documentation; patient-reported outcome measures (PROMs) such as rapid, real-time pain feedback; to augment EHR PC data capture capabilities; and to enhance interdisciplinary communication and care.

Discussion

Beginning in 2015, there was a proliferation of articles about PC and EHRs, suggesting increasing incorporation of and research about the EHR with PC. This review indicates the EHR is underutilized for PC CDS, facilitating PROMs, and capturing ACPs.

Impact of Palliative Care Consultations on Resource Utilization in the Final 48 to 72 Hours of Life at an Acute Care Hospital in Ontario, Canada

A wealth of literature and economic analyses has shown that palliative care is associated with significant cost reductions compared to nonpalliative care. However, no one has assessed the impact of an inpatient palliative care consultation service on costs at the very end of life (48 to 72 hours before death). This retrospective cohort review of 100 inpatients at a large hospital in Ontario examines the effect of palliative care consultations on seven independent cost categories during this period: medical-imaging costs, physician costs, laboratory costs, pharmaceutical costs, other health professional costs, food services costs, and unit costs. Our study shows that patients who receive palliative care consultations are associated with significantly lower costs in the final 48 to 72 hours of life than their nonpalliative counterparts. Another significant finding was that the degree of cost reduction at the very end of life appears to be relative to how soon after the patient's admission the palliative care consultation was initiated.

Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral

BACKGROUND

The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease.

OBJECTIVES

To investigate the effectiveness of our AI Management program in the ED on key outcomes.

METHODS

We conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate.

RESULTS

Our sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001).

CONCLUSIONS

The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.

Characteristics of patients with an unplanned admission to an acute palliative care unit

The aim of this cohort study is to compare the symptom burden of patients who have an unplanned admission to an acute palliative care unit (APCU) with patients who have a regular planned admission. A consecutive sample of advanced cancer patients who were admitted to an APCU was prospectively assessed. The reasons and the kind of admission were recorded (unplanned, UP, or planned, P). Anticancer treatments, whether patients were on/off treatment or uncertain, previous care setting, and who referred the patient to the unit were also recorded. The Edmonton Symptom Assessment Scale (ESAS) was used at admission and at time of discharge, as well as the Memorial Delirium Assessment Scale. Analgesics and their doses at admission and discharge were recorded. Hospital staying was also recorded. At the time of discharge, subsequent referral to other care settings, and the pathway of oncologic treatment were re-considered. Fifty-five (17.5%) of 314 consecutive admissions recorded in a period of 10 months were UP. UP-patients are more frequently referred from other hospitals (P = 0.0005), and are reported by physicians of other units (P = 0.05). UP-patients have a longer hospital admission (P = 0.032), a higher hospital death rate (P = 0.025), and are less frequently discharged home (P = 0.031). A significant decrease in intensity of ESAS items was observed in both groups, with no differences in symptom burden either at admission and time for discharge. At discharge, opioid doses are higher in UP-patients. An APCU may admit UP-patients at any stage of disease, providing effective treatment outcomes, as reported with P-patients. This study suggests that patients referred from other settings or hospitals may provide specialist advice and rapid symptom control. Although symptom burden is similar, these patients have longer hospital admission, higher hospital death rate, and are less frequently discharged home, suggesting the need for more complex treatments. Such units in a comprehensive cancer center might improve symptom control and pose as referral centers for non-cancer hospitals, emergency departments, or the territory.

The Palliative Performance Scale Predicts Three- and Six-Month Survival in Older Adult Patients Admitted to the Hospital through the Emergency Department

BACKGROUND

There is often little information on long-term prognosis available for Emergency Medicine physicians when decisions on admission, treatment, or consultations are being made for patients. There is a new focus to understand if palliative support should be offered in the emergency department (ED) and the Palliative Performance Scale (PPS), a screening tool used in other settings in palliative care, has been little used in the ED.

OBJECTIVE

The goal of this study was to assess the prognostic value of the PPS in predicting three- and six-month survival in patients admitted through the ED.

DESIGN

A prospective cohort study.

SETTING/SUBJECTS

We evaluated 123 patients over the age of 55 years admitted through the ED of a tertiary care hospital in New England in November and December of 2013.

MEASUREMENTS

Each patient's PPS score was evaluated initially in the ED, with follow-up assessments of PPS and survival at three and six months.

RESULTS

Baseline PPS for the 123 patients was 72 ± 22. Information on 72 subjects (58.5%) at three months was 60 assessed and 12 deaths. Information on 47 subjects (38.2%) at six months was 26 assessed and 21 deaths (nine further deaths from three months). There were no significant differences in the demographics or PPS score in those evaluated and those lost to follow-up at three or six months. Patients with an initial PPS score of 30 or less had 14% survival at six months.

CONCLUSION

In this small preliminary study, The PPS score may predict survival in patients admitted to the hospital through the ED. The ease of use holds promise that use of the PPS in the ED may help ED physicians predict survival and plan for better disposition, advocate for patient wishes, and initiate palliative care consultation.

Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors

CONTEXT

Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority.

OBJECTIVES

To assess PC competency education in EM residency programs.

METHODS

This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training.

RESULTS

Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues.

CONCLUSION

There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.

Presenting Symptoms in the Emergency Department as Predictors of Intensive Care Unit Admissions and Hospital Mortality in a Comprehensive Cancer Center

PURPOSE

The identification of patients at high risk for poor outcomes may allow for earlier palliative care and prevent futile interventions. We examined the association of presenting symptoms on risk of intensive care unit (ICU) admission and hospital death among patients with cancer admitted through an emergency department (ED).

METHODS

We queried MD Anderson Cancer Center databases for all patients who visited the ED in 2010. Presenting symptoms, ICU admissions, and hospital deaths were reviewed; patient data analyzed; and risk factors for ICU admission and hospital mortality identified.

RESULTS

The main presenting symptoms were pain, fever, and respiratory distress. Of the patients with cancer who visited the ED, 5,362 (58%) were admitted to the hospital at least once (range, 1 to 13 admissions), 697 (13%) were admitted to the ICU at least once, and 587 (11%) died during hospitalization (31% of 233 patients with hematologic malignancies and 27% of 354 patients with solid tumors died in the ICU; P < .001). In multivariable logistic regression, presenting symptoms of respiratory distress or altered mental status; lung cancer, leukemia, or lymphoma; and nonwhite race were independent predictors of hospital death. Patients who died had a longer median length of hospital stay than patients discharged alive (14 v 6 days for hematologic malignancies and 7 v 5 days for solid tumors; P < .001).

CONCLUSION

Patients with cancer admitted through an ED experience high ICU admission and hospital mortality rates. Patients with advanced cancer and respiratory distress or altered mental status may benefit from palliative care that avoids unnecessary interventions.

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.

Emergency medicine and palliative care

The emergency department cares for seriously ill patients across the trajectory of illness from diagnosis to death or cure. Emergency departments participate in critical illness trajectories that include initiation of life-sustaining therapies as well as caring for patients and families in their final moments of life. Emergency clinicians are uniquely poised to identify critical palliative care interventions to be used when patients and families are most in need with respect to symptom management, decisions regarding intervention and procedures to sustain life and participate in critically important decisions regarding withdrawing and withholding nonbeneficial life-sustaining therapies.

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

CONTEXT

Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable.

OBJECTIVES

To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).

METHODS

We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED.

RESULTS

Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99).

CONCLUSION

Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.

Emergency department-triggered palliative care in advanced cancer: proof of concept

BACKGROUND

The American College of Emergency Physicians and the American Society of Clinical Oncology recommend early palliative care consultation for patients with advanced, life-limiting illnesses, such as metastatic cancer.

OBJECTIVES

The objectives were to assess the process of early referral from the emergency department (ED) to palliative care for patients with advanced, incurable cancer as part of a randomized controlled trial and to compare the proportion and timing of consultation to a care as usual group.

METHODS

A single-blind randomized controlled trial (ClinicalTrials.gov ID NCT01358110) compared early, ED-based referrals to palliative care for patients admitted with advanced, incurable cancer to physician-driven consultation (i.e., care as usual). Participants had to speak English or Spanish and have no history of palliative care consultation. They were randomized via balanced block randomization to the intervention or control group. Each intervention subject was referred by a research staff member to the palliative care team for consultation. The usual care group received palliative care only if requested by the admitting physician. Analysis was based on intention to treat. A chart review was performed to assess proportion and timing of palliative care consults during the index admission, defined as: (1) completed palliative care consult documented in the chart and (2) days from admission to palliative care consult.

RESULTS

A total of 134 participants were enrolled and randomized. For patients in the intervention group, 88% (60 of 68) had documented palliative care consultations during their index admissions (95% confidence interval [CI] = 80.5 to 95.5), compared to 18% (12 of 66) in the control group (95% CI = 8.8 to 27.5; p < 0.01). The 60 intervention patients received palliative care consultations on average 1.48 days from admission (95% CI = 1.19 to 1.76), compared to 2.9 days from admission in the 12 control patients (95% CI = 1.03 to 4.79; p = 0.15).

CONCLUSIONS

This study documented a low baseline rate of palliative care involvement as part of usual care in patients with advanced cancer being admitted from the ED. Early referral to palliative care in the context of a research study significantly increased the likelihood that patients received a consult, thus meriting further investigation of how to generalize this approach.

Prehospital Providers’ Perceptions of Emergency Calls Near Life’s End

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers’ perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory–descriptive pilot study was survey based and cross-sectional. Calls to nursing homes occur most often, (47.8% every shift). The MOLST was seen infrequently (57.9% rarely never). The most frequent signs and symptoms of dying were diagnosis (76%), hospice involvement (82%), apnea (75%), mottling (55%), and shortness of breath (48%). The MOLST identifies wishes about intubation (74%), resuscitation (74%), life-sustaining treatment (72%), and cardiopulmonary resuscitation (70%). Synergy exists between the fields of prehospital, hospice, and palliative medicine which offers potential for improved education and care.

Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death

BACKGROUND

Overcrowded emergency departments (EDs) and the staff within them are often not able to address the complex physical and psychosocial needs of people at the end of life. While some studies have suggested that the ED environment should be adapted and staff trained to address this issue, there are no previous studies which have investigated whether the provision of timely palliative care services could prevent people with palliative care needs from attending EDs.

OBJECTIVE

This study investigates whether early admission to community-based palliative care reduces ED admissions in the last 90 days of life for patients with cancer.

METHODS

The study was a retrospective, cross-sectional study using death registrations and hospital morbidity data for 746 Western Australian adults who died of cancer and where palliative care may have been a viable and appropriate option for care.

RESULTS

In their final 90 days before death, 31.3% of decedents who had early access to palliative care and 52.0% of those who did not have early access to palliative care visited an ED (OR=2.86; 95% CI, 1.91, 4.30). Early admission to community-based palliative care reduces the use of EDs by cancer patients in the 90 days before death.

CONCLUSIONS

Proactive care in the form of timely community-based palliative care assists in preventing vulnerable people at the end of life from being exposed to the stressful ED environment and decreases the pressure on EDs.

Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative

STUDY OBJECTIVE

We describe 11 clinical demonstrations of emergency department (ED) and palliative care integration to include traditional consultation services with hospital-based palliative care consultants through advanced integration demonstrations in which the ED provides subspecialty palliative care practice.

METHODS

An interview guide was developed by the Improving Palliative Care in Emergency Medicine board that consists of emergency clinicians and palliative care practitioners. Structured interviews of 11 program leaders were conducted to describe the following key elements of the ED-palliative care integration, to include structure, function, and process of the programs, as well as strengths, areas of improvement, and any tools or outcome measures developed.

RESULTS

In this limited number of programs, a variety of strategies are used to integrate palliative care in the ED, from traditional consultation to well-defined partnerships that include board-certified emergency clinicians in hospice and palliative medicine.

CONCLUSION

A variety of methods to integrate palliative care in the emergency setting have emerged. Few programs collect outcomes-based metrics, and there is a lack of standardization about what metrics are tracked when tracking occurs.

Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles

Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.