Hospice and Comfort Care Patient Utilization of Emergency Medical Services

Characteristics of patients enrolled in hospice presenting to the emergency department

OBJECTIVES

Emergency Departments (EDs) frequently care for patients with life-limiting illnesses, with nearly 1 in 5 patients enrolled in hospice presenting to an ED during their hospice enrollment. This study investigates the reasons patients enrolled in hospice seek care in the ED, the interventions they receive, and their outcomes.

METHODS

Multicenter, retrospective cohort study of patients enrolled in hospice who presented to an ED within a health system between 2018 and 2023. Descriptive analysis included patient characteristics, chief complaint, interventions, disposition, ED return visits and mortality. Comparisons were made via logistic regression between patients with a hospice enrollment diagnosis of cancer vs non-cancer diagnosis, patients enrolled in hospice for <30 days vs those enrolled for ≥30 days, and patients admitted to the hospital compared with patients not admitted.

RESULTS

A total of 119 ED visits by patients enrolled in hospice were identified. Patient median age was 85 (IQR: 68-92) years, 38 % were female, and 86 % were White. Hospice diagnoses included cancer (31 %), heart disease (21 %), lung disease (13 %), and dementia (13 %). At the time of ED visit, patients were enrolled in hospice for a median of 71 (IQR: 17-162) days. Patients primarily presented via emergency medical services (EMS) (76 %) from a home residence (51 %). The most common reasons for ED visit were trauma (36 %), pain (15 %) and catheter/tube malfunction (12 %). Most patients received laboratory studies (60 %), medications (66 %) and imaging (64 %). A total of 45 % were admitted to the hospital, with 2 % expiring in the ED. Patients admitted to the hospital were more likely to be receiving hospice services at home (66 % vs. 34 %, p = 0.003). Seven-day mortality was 20 % and 30-day mortality was 38 %. Ten percent returned to the ED within 7 days and 17 % within 30 days. Patients enrolled in hospice for ≥30 days were less likely to return (30 % vs. 51 %, OR 0.26, 95 % CI 0.075-0.94) or die (30 % vs 51 %, OR 0.40, 95 % CI 0.19-0.87) within 30 days compared to those enrolled for <30 days. Patients with a hospice diagnosis of cancer were more likely to die within 7 days (32 % vs 15 %, OR 2.78, 95 % CI 1.11-7.04) compared to patients with a non-cancer hospice diagnosis. In addition, those with a cancer hospice diagnosis (62 % vs 27 %, OR 4.48, 95 % CI 1.96-10.22) and those admitted to the hospital (48 % vs 16 %, OR 2.38, 95 % CI 1.11-5.11) were more likely to die at 30 days than those with a non-cancer enrollment diagnosis or those not admitted, respectively.

CONCLUSION

Patients enrolled in hospice most frequently presented to the ED for trauma. Most received laboratory studies and imaging. Nearly half of patients were admitted to the hospital and short-term mortality was high, particularly for patients enrolled in hospice for <30 days, enrolled with a hospice diagnosis of cancer, or admitted to the hospital. Understanding the care patients enrolled in hospice receive in the ED can help prevent avoidable visits and ensure care aligns with patients' goals.

End-of-life Care, Comfort Care, and Hospice: Terms and Concepts

Purpose

This study aims to clarify and standardize the terms and concepts associated with end-of-life care, specifically within the contexts of hospice and palliative care.

Methods

We reviewed references pertaining to hospice and palliative care, including definitions of end-of-life care and comfort care. Two meetings were held with members of the medical terminology committee of the Korean Society for Hospice and Palliative Care, along with experts in the field, to establish a consensus on the terms used. In the first round, six experts participated, and in the second round, eight experts engaged in online meetings to brainstorm, exchange opinions, and review and discuss reference materials concerning terms related to hospice and palliative care.

Results

Legal definitions do not always align with those used in clinical medical settings. Although it is challenging to define the period precisely, end-of-life care encompasses all diseases, including age-related infirmities, typically spanning 6 months to 1 year. Hospice care, in contrast, includes certain non-cancerous terminal diseases as well as terminal cancer, covering a period of 3 to 6 months. Comfort care generally refers to the care provided approximately 7 days before death.

Conclusion

A conceptual understanding of terms related to end-of-life care must be reached through cultural and social consensus. Furthermore, end-of-life care should not be limited to cancer but extended to all diseases. In the future, the scope of end-of-life care should expand to encompass care for bereaved families, evolving into a more comprehensive concept of comfort care.

Asynchronous education improves emergency medical services clinician confidence and knowledge in caring for patients near the end-of-life

Objective

To evaluate the impact of a nationally available continuing education online curriculum on Emergency Medical Services (EMS) clinician confidence and knowledge in caring for end-of-life (EOL) patients.

Methods

This is a prospective observational study of EMS clinicians (emergency medical technicians [EMTs], advanced EMTs [AEMTs], and paramedics). EMS clinicians and physicians with both EMS and palliative care expertise developed two 20-min modules regarding: (1) communication skills (including death notification) and (2) hospice knowledge. EMS clinicians' subject confidence (modified Likert-scale) and knowledge were assessed electronically immediately before and after each module. Data analysis compared before and after module improvements in knowledge and confidence. Linear regressions analyzed baseline EOL skill confidence scores based on EMS agency, level of certification, and years of experience.

Results

We analyzed completed datasets for 1825 EMS clinicians (979 EMTs, 112 AEMTs, and 734 paramedics) representing a heterogeneous cohort across different EMS agencies (617 private, 545 fire-based, 298 hospital-based, 61 third service, and 304 other) and all 50 states and the District of Columbia. After the communication module, the number of EMS clinicians who reported confidence in delivering bad news increased from 62% (1131/1825) to 80% (1468/1825) (p < 0.001). After the hospice module, the number of EMS clinicians who reported confidence in knowing what services hospice provides increased from 51% (925/1825) to 75% (1375/1825) (p < 0.001) and confidence in knowing what active dying patients look like from 57% (1033/1825) to 78% (1429/1835) (p < 0.001) in knowing what active dying patients look like. Linear regression demonstrated that before modules, EMS clinicians with more monthly EOL calls, those with more years of experience, and paramedics were more confident in their EOL skills than their peers. After module completion, those with the fewest years of experience (0-3 years) and EMTs gained significantly more confidence in communication skills than their peers.

Conclusion

Asynchronous, online continuing education improves EMS clinician knowledge and confidence in caring for patients near the EOL. The greatest benefit in improved confidence was for EMTs and those with the fewest years of EMS experience.

Emergency medical services and palliative care: a scoping review

OBJECTIVES

The aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present?

DESIGN

A scoping review of literature was performed with an a priori search strategy.

DATA SOURCES

MEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines.

RESULTS

In total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS' palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration.

CONCLUSION

EMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.

Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot

Background: Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention to reach patients at greatest risk for opioid-related death. Emergency Medical Services (EMS) patients who are at high risk for overdose deaths may never engage in treatment as they frequently refuse transport to the hospital after naloxone reversal. The potentially important role of EMS as the initiator for medication for opioid use disorder (MOUD) in the most high-risk patients has not been well described. Setting: This project relies on four interventions: a public access naloxone distribution program, an electronic trigger and data sharing program, an "Overdose Receiving Center," and a paramedic initiated buprenorphine treatment. For the final intervention, paramedics followed a protocol based pilot which had an EMS physician consultation prior to administration. Results: There were 36 patients enrolled in the trial study in the first year who received buprenorphine. Of those patients receiving buprenorphine, only one patient signed out against medical advice on scene. All other patients were transported to an emergency department and their clinical outcome and 7 and 30 day follow ups were determined by the substance use navigator (SUN.) 36 of 36 patients had follow up data obtained in the short term and none experienced any precipitated withdrawal or other adverse outcomes. Patients had a 50% (18/36) rate of treatment retention at 7 days and 36% (14/36) were in treatment at 30 days. Conclusion: In this small pilot project, paramedic initiated buprenorphine in the setting of data sharing and linkage with treatment appears to be a safe intervention with a high rate of ongoing outpatient treatment for risk of fatal opioid overdoses.