Outcomes for Emergency Presentations of Lung Cancer: A Scoping Review

BACKGROUND

Lung cancer is frequently detected during visits to the emergency department (ED). The ED is crucial for identifying likely cases of lung cancer and coordinating the subsequent care for these patients.

OBJECTIVES

This scoping review aims to explore the definitions of emergency presentations (EPs) of lung cancer, along with mortality rates, cancer stage, and treatments for patients diagnosed with lung cancer following an EP.

METHODS

We conducted a scoping review of the literature on EPs of lung cancer, identifying 27 relevant articles out of 1338 initially screened.

RESULTS

Most studies originated from the United Kingdom, collectively reporting over 270,000 EPs of lung cancer. The majority of included studies provided strong evidence. Key findings revealed higher mortality rates among patients diagnosed with lung cancer through emergency presentations, with a significant proportion presenting at advanced stages. Patients with EPs were less likely to undergo surgical removal or receive radiotherapy. Lastly, only 66.7% of the studies defined an EP, with great heterogeneity among EP definitions. Methodological differences precluded meta-analysis.

CONCLUSION

Despite methodological heterogeneity, our synthesis indicates that patients presenting acutely with undiagnosed lung cancer often present at advanced stages and experience high mortality rates. These findings underscore the need for further research to develop evidence-based interventions for improving outcomes among ED patients with suspected lung cancer.

The power of partnership: Strategies for pan-Canadian spread and scale of paramedics providing palliative care

Paramedics and Palliative Care is an example of a promising practice ("pilot") that underwent successful spread and scale across Canada. Through the support of two pan-Canadian health organizations and concurrent evolution of the profession of paramedicine, this innovation has become integrated into practice. Evaluation of the innovation sites showed positive impact in all elements of the Quintuple Aim, and data from the expansion sites mirrors this success. Paramedic comfort and confidence is improved. Patient and family satisfaction is high. Quality indicators such as time spent at home, and home deaths, improved after program launch. There are time and cost savings with the program in place. The framework that enabled this spread and scale is presented and elaborated, to support further uptake of this innovation and provide a blueprint for successful expansion of other promising practices to support healthcare improvement across Canada.

Emergency department use and responsiveness to the palliative care needs of patients with dementia at the end of life: A scoping review

OBJECTIVES

More than 50% of patients with dementia visit the emergency department (ED) each year. Patients with dementia experience frequently unrelieved symptoms that can benefit from palliative care. Response to palliative care needs in the ED can be quite challenging and access to palliative care is generally scarce. The aim of this scoping review is to assess ED use and responsiveness to palliative care needs of patients with dementia in their last year of life.

METHODS

A scoping literature review following the Joanna Briggs Institute methodology. Electronic search of the literature was undertaken in Medline (PubMed), Web of Science, Scopus, Scielo, and APA PsycInfo, last updated on 19 February 2024.

RESULTS

Twenty-four studies were identified and confirmed that patients with dementia frequently resort to the ED near the end of life, frequently more than once in their last year of life. Eight studies directly addressed palliative care needs, suggesting significant rates of palliative care needs among patients with dementia and in comparison, to other oncological or non-oncological conditions. Infections and neuropsychiatric symptoms were the main reasons of admission to the ED. Access to palliative care was confirmed to be low.

SIGNIFICANCE OF RESULTS

This scoping review indicates that patients with dementia frequently resource to the ED in their last year of life with unmet palliative care needs. Although scarce access to palliative care and the existence of important barriers in the ED, palliative care intervention in this setting can be seen as an opportunity to attend palliative care needs and referral to palliative care services.

Mapping Palliative Care Availability and Accessibility: A First Step to Eradicating Access Deserts in the Low- and Middle-Income Settings

OBJECTIVE

Palliative care is unavailable and/or inaccessible for the majority of people in low- and middle-income countries (LMIC). This study aims to determine the availability and accessibility of palliative care services in Malaysia, a middle-income country that has made good progress toward universal health coverage (UHC).

METHOD

Publicly available data, and databases of registered palliative care services were obtained from governmental and nongovernmental sources. Google Maps and Rome2Rio web-based applications were used to assess geographical disparities by estimating the median distance, travel time, and travel costs from every Malaysian district to the closest palliative care service.

RESULTS

Substantial variations in availability, components, and accessibility (distance, time, and cost to access care) of palliative care services were observed. In the highly developed Central Region of Peninsular Malaysia, specialty care was available within 4 km whereas in the less-developed East Coast of Peninsular Malaysia, patients had to travel approximately 46 km. In the predominantly rural East Malaysia, basic palliative care services were 82 km away and, in some instances, where land connectivity was scarce, it took 2.5 h to access care via boat. The corresponding median travel costs were USD2 (RM9) and USD23 (RM114) in Peninsular Malaysia and East Malaysia.

CONCLUSION

The stark urban-rural divide in the availability and accessibility of palliative care services even in a setting that has made good progress toward UHC highlights the urgent need for decentralization of palliative care in the LMICs. This may be achieved by capacity building and task shifting in primary care and community settings.

Economic evaluation of the "paramedics and palliative care: bringing vital services to Canadians" program compared to the status quo

OBJECTIVE

Based on programs implemented in 2011-2013 in three Canadian provinces to improve the support paramedics provide to people receiving palliative care, the Canadian Partnership Against Cancer and Healthcare Excellence Canada provided support and funding from 2018 to 2022 to spread this approach in Canada. The study objectives were to conduct an economic evaluation of "the Program" compared to the status quo.

METHODS

A probabilistic decision analytic model was used to compare the expected costs, the quality-adjusted life years (QALYs) and the return on investment associated with the Program compared to the status quo from a publicly funded healthcare payer perspective. Effectiveness data and Program costs, expressed in 2022 Canadian dollars, from each jurisdiction were supplemented with literature data. Probabilistic sensitivity analyses varying key model assumptions were conducted.

RESULTS

Analyses of 5416 9-1-1 calls from five jurisdictions where paramedics provided support to people with palliative care needs between April 1, 2020 and March 31, 2022 indicated that 60% of the 9-1-1 calls under the Program enabled people to avoid transport to the emergency department and receive palliative care at home. Treating people at home saved paramedics an average of 31 min (range from 15 to 67). The Program was associated with cost savings of $2773 (95% confidence interval [CI] $1539-$4352) and an additional 0.00069 QALYs (95% CI 0.00024-0.00137) per 9-1-1 palliative care call. The Program return on investment was $4.6 for every $1 invested. Threshold analyses indicated that in order to be cost saving, 33% of 9-1-1 calls should be treated at home under the Program, the Program should generate a minimum of 97 calls per year with each call costing no more than $2773.

CONCLUSION

The Program was cost-effective in the majority of the scenarios examined. These results support the implementation of paramedic-based palliative care at home programs in Canada.

Emergency Department Management of Common End-of-Life and Palliative Care Symptoms: Three Cases

The emergency department (ED) is at times the only place where patients can turn for symptom relief. Patients of all ages may turn to the ED for help with the management of end-of-life (EOL) and palliative care (PC) symptoms. Emergency medicine (EM) is a specialty that manages disease-directed treatment for a variety of acute conditions. In contrast, EOL and PC are focused on improving quality of life. Patients with serious illness, even hospice patients, present to the ED in increasing numbers for symptom management. It has become essential for emergency physicians to care for patients who are not seeking life-sustaining measures but instead need quality-of-life interventions. The development of a clear, concise review of the most common acute symptoms can provide a framework for EM physicians to adequately address the needs of patients at the EOL. Here, we discuss three cases that highlight the management of five of the most common EOL and PC presentations to the ED.

Patients requiring palliative care attending a regional hospital emergency centre in South Africa: A descriptive study

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Conducted in a regional emergency centre in the Western Cape, South Africa.

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Provides an insight into the prevalence of the palliative care population in an African context, specifically with the high burden of HIV and TB.

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Informs about unique challenges that are faced by emergency centers in the sub Saharan region.

Background

: Globally, emergency centers (ECs) face increasing patients with palliative care (PC) needs. This is also true for South Africa. Factors include an increasingly older population, rising rates of non-communicable and infectious diseases. A paucity of data exists on local rates and reasons for patients with life limiting conditions presenting to ECs. PC and emergency medicine are established specialties, but little is known how they interface in clinical practice. This study describes the contribution of patients with life limiting conditions to the case load of an EC in a regional hospital in the Western Cape.

Methods

: This was a prospective, descriptive study. All patients entering the EC over 3 months were assessed using a validated PC identification tool, developed for low-and-middle-income countries. All patients entering the EC were captured in an electronic database. Those identified to have life limiting illnesses and potential PC needs received a secondary ICD-10 code. These files were extracted and statistically analysed. Variables included diagnosis, demographics, reason for visit, and disposition.

Results

: A total of 426 patient visits (4.24%) were identified. Cancer (25.8%), neurological (19.7%) and HIV (17.4%) were the most frequent diagnoses. Patients with HIV and TB were significantly younger. Physical symptoms were the most common reasons for attendance (87%), followed by social (11%) and system issues (10%). Most patients were discharged home (55%), 26% were admitted, and 13% died in the EC.

Discussion

: ECs in Africa are under-resourced and uncomfortable places for patients with life limiting illnesses. System-related visits could be avoidable, as most were due to patients running out of medication or requiring procedures such as urinary catheter changes, which could be done at the local clinic. Some attended EC due to social reasons, usually due to caregivers feeling overwhelmed. Patients requiring PC make up a significant percentage of EC visits. Optimizing health systems and community home-based care could alleviate EC pressures and improve the illness experience of patients with life limiting conditions.

Providing palliative care at home aligns with the professional identity of paramedics: a qualitative study of paramedics and palliative health care providers

BACKGROUND

An innovative program, 'Paramedics Providing Palliative Care at Home,' was implemented in Nova Scotia, Canada in 2015. Roles like this are part of an evolving professional identity; role discordance or lack of clarity not only hinders professionalization but may impair the wellbeing, and career longevity of paramedics. This study explored the alignment of providing palliative support at home with paramedic professional identity.

METHODS

Qualitative description was employed, with thematic analysis of focus groups with paramedics and palliative health care providers. Recruitment posters were sent through the professional college (paramedics) and program managers (health care providers). Focus groups followed a semi-structured guide, discussing understanding of and experiences with the role and its alignment with professional identity. Challenges to paramedic palliative support and fit with professional identify were explored. Thematic content analysis was ongoing while focus groups were being conducted, until no new codes were found. Codes were combined, sorted into categories, and ultimately, agreed-upon themes. Saturation of themes was reached.

RESULTS

Eleven paramedics and twenty palliative health care providers participated. Four themes reflected paramedic's expanded role: (1) patient centeredness and job satisfaction with provision of palliative support, (2) a bridging role, (3) paramedic as advocate and educator, (4) provision of psychosocial support. Four themes reflected paramedic's professional identity: (1) evolution of paramedicine as a skilled clinical profession, (2) helping people and communities, (3) paramedic skill set aligns with work in palliative care, and (4) changing paramedic mindset.

CONCLUSION

Paramedics and palliative health care providers highlighted the provision of palliative care as part of a positive growth of paramedicine as a health profession, and a good fit with professional identity. Novel roles like this are important in the evolution of our health care system faced with increasing pressures to get the right care with the right provider at the right time.

Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department

Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand

Background

The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality.

Methods

A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included.

Results

A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was ‘cannot control symptoms’ (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality.

Conclusion

The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01009-z.

Essential Elements to Implementing a Paramedic Palliative Model of Care: An Application of the Consolidated Framework for Implementation Research

Background: Comfort care without transport to hospital was not traditionally a paramedic practice. The novel Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to manage and share goals of care, and palliative care training. This study determined essential elements for implementation, scale, and spread of this Program. Methods: Deliberative dialogs, a qualitative method, were held with diverse stakeholders/experts in one province with the Program (Nova Scotia, March 2018) and one without (British Columbia, July 2018). The Consolidated Framework for Implementation Research (CFIR) informed the discussion guide and was used in a framework analysis. Four team members analyzed the data independently; themes were derived by consensus with the broader research team. Results: CFIR constructs framed several key elements. Inter-sectoral communication is critical but challenged by privacy concerns and the siloed structure of the health system. Locally adapted training is an essential characteristic of the intervention; cost is a factor. A shift in mindset away from traditional paramedic roles is required; this can be facilitated by paramedic champions and a positive implementation climate. Early engagement of diverse stakeholders and planning for sustainability is key. Conclusion: This framework analysis using CFIR constructs can guide successful scale and spread of the program. The constructs of Outer setting: Cosmopolitanism; Characteristics of the intervention: Adaptability; Inner Setting: Implementation climate; and Processes: Engagement, and Planning, emerged as essential.

Emergency Department Utilisation by Palliative Patients in a Regional Australian Setting

BACKGROUND

Many palliative care patients attend emergency departments (EDs) in acute Hospital. However, very limited studies inform about their presentations and appropriateness.

OBJECTIVES

This study explored the reasons and appropriateness of palliative care presentations in a regional Australian ED setting.

METHODS

A retrospective, single-centre observational study was conducted in a regional Australian hospital. All patients between January and December 2018 known to palliative care services presented to ED were included. Appropriateness of presentations was determined based on urgency of tests and treatments received, and practicability of obtaining these in a different setting.

RESULTS

A total of 35 patients made 85 presentations to the ED in 2018. The most common individual presenting complaints were shortness of breath (18.9%) followed by pain (14.1%), fever (11.8%), fall (8.2%), reduced oral intake or dehydration (8.2%), and bleeding (8.2%). The patients were brought by an ambulance in 56.5% presentations, and 63.5% presentations were admitted. About 93% presentations were referred by community healthcare professionals or required urgent investigation or management.

CONCLUSIONS

This study found the majority of presentations were appropriate since their management could not be delivered at other primary care settings. This study adds value to the growing body of evidence and supports future multi-site longitudinal studies.

Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs

INTRODUCTION

This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared.

METHODS

Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs.

CONCLUSIONS

Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.

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.

Safe Delivery of Surgical Care in Head and Neck Cancer Patients During COVID-19-an Audit of Pattern of Presentation and Treatment Strategies in an Oncology Centre in the Northern India

Delay in treatment of head and neck cancer leads to stage migration and increased morbidity. Due to the COVID-19, surgical care has been severely affected. We continued our oncology services during the pandemic. We present here the pattern of presentation of head and neck cancer patients to the hospital and strategy to continue services. A retrospective audit of patients registered under Head and Neck Disease Management Group during lockdown, 23rd March to 31st May 2020, was done. Four categories were made new registrations, post-surgical patients, emergency department visits and follow-up presentation. Of the 693 patients assessed, a majority were with oral cavity cancer (80%). Seventy-eight percent of patients presented with stage IV disease. There were 382 new registrations, of which 68% were symptomatic. Of the 69 patients that underwent surgery, 17 patients were on adjuvant treatment. A total of 60 patients presented to emergency department during this period, maximum with complaints of dyspnoea (67%). One hundred eighty-nine patients were follow-up patients of which 43% were symptomatic. Among these, 12 patients were diagnosed with recurrence. Various administrative and clinical policies were formulated to continue cancer care during this time. Surgical services need not be halted during the COVID-19 pandemic. Following scientific rationale and treatment strategies, safe oncosurgical care can be delivered during pandemic.

What Do We Know About Pediatric Palliative Care Patients Consulting to the Pediatric Emergency Department?

OBJECTIVES

The objective of this study was to describe the characteristics of pediatric palliative care (PPC) patients presenting to a pediatric emergency department (ED) and these patients' ED visits.

METHODS

This retrospective chart review was conducted from April 1, 2007, to March 31, 2012, in a tertiary care pediatric university-affiliated hospital. Eligible patients had initial PPC consultations during the study period; all ED visits by these patients were included. Data were drawn from the ED's electronic data system and patient's medical chart.

RESULTS

A total of 290 new patients were followed by the PPC team, and 94 (32.4%) consulted the ED. Pediatric palliative care patients who consulted the ED had a median age of 7 years and baseline diagnoses of cancer (39.4%) or encephalopathy (27.7%). No patients died in the ED, but 36 (38.3%) died in hospital after an ED visit and 18 (19.1%) within 72 hours of admission. Pediatric palliative care patients consulted 219 times, with a median number of visits per patient of 2 (range, 1-8). They presented acutely ill as per triage scales. Reasons for consultation included respiratory distress/dyspnea (30.6%), pain (12.8%), seizure (11.4%), and fever (9.1%). Patients were often admitted to wards (61.2%) and the pediatric intensive care unit (7.3%). Two thirds (65.7%) of patients had signed an advanced care directive at the time of their visit. Discussions about goals of care occurred in 37.4% of visits.

CONCLUSIONS

Pediatric palliative care patients present to the ED acutely ill, often at their end of life, and goals of care are not always discussed. This is a first step toward understanding how to improve PPC patients' ED care.

Emergency Department Use by Terminally Ill Patients: A Systematic Review

CONTEXT

Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.

OBJECTIVE

To determine the prevalence of TIP visiting the ED.

METHODS

Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I²).

RESULTS

We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37-54%] and 75% in the last six months of life [95% CI 62-83%]; I² = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12-23%]; I² = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping.

CONCLUSIONS

Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

Characteristics of Advanced Cancer Patients Admitted to the Palliative Care Unit from the Emergency Department

Aim:

People with cancer frequently present to emergency departments (EDs) because of exacerbation of the existing problems and new symptoms, complications of treatments, or difficulties with care and support systems. The aim of the study was to determine the presenting symptoms and demographic characteristics of advanced cancer patients and their caregivers admitted to the palliative care (PC) unit from the ED.

Methods:

After approval, 139 cancer patients admitted to the ED and referred for PC consultation were included in the study. The medical records of PC unit for all patients and their primary caregivers were retrospectively evaluated. Demographic characteristics, cancer site and metastasis, reasons and frequency for ED admissions, symptoms, duration of hospitalization, and outcomes were recorded. The association between the characteristics of caregivers and emergency visits was also evaluated.

Results:

Among all patients, 61.9% were >60 years old, 58.3% were male, and 71.2% were married. The most frequent site of cancer was gastrointestinal system (39.6%), lungs (18.7%), and genitourinary system (12.2%). The reasons for emergency visits were found as inadequate symptom control (65.5%), dying patient (30.2%), lack of psychosocial support (3.6%), and symptom of other comorbidities (0.7%). The most frequent symptoms were feeling of not well-being, tiredness, and lack of appetite. There was no difference in the number of admissions according to caregivers. Ninety-seven patients (69.8%) died at the PC unit and 42 (30.2%) were discharged.

Conclusion:

PC system needs to be integrated into all health-care disciplines including EDs. While improving a community- and home-based PC, education of patients, caregivers, and health professionals must also be provided.

Determination of the characteristics and outcomes of the palliative care patients admitted to the emergency department

OBJECTIVES

Terminally ill patients in need of palliative care present to emergency departments. This study aims to identify the usage level of the emergency departments by patients in need of palliative care, along with their experienced symptoms, preferences, needs, and the subsequent initiatives taken for symptom management.

METHODS

The study was designed as a cross-sectional study and conducted with a group of 208 patients. The Patient Information Form, the Form of the Criteria for Receiving Palliative Care, and the Karnofsky Performance Scale were used for data collection.

RESULTS

This report founda thatcancer patients were the most frequent users of emergency facilities within palliative care patient groups and more than half of those hospitalized patients were subsequently admitted to intensive care units. Patients with poorer functional conditions and in need of further palliative care preferred home care rather than receiving Advanced Cardiac Life Support.

CONCLUSION

This study displays evidence that palliative care patients with a poorer functional condition in need of further palliative care should be able to spend the last days of their lives at home with their families rather than in the exhausting and crowded environment of the emergency departments. Furthermore, healthcare policymakers should actively support palliative care as well as taking the necessary actions to mitigate the burden placed on hospital resources.

A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions

Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.

Navigating the impact of COVID-19 on palliative care for head and neck cancer

Health care services are being confronted by a daily dilemma of who can receive critical care and who cannot. In a palliative care clinic, this apprehension gets exemplified, as these patients have limited life expectancy. The head and neck region further makes things critical, as it comprises of all the sites through which the SARS‐CoV‐2 can be transmitted. This document strives to define the ways in which the head and neck cancer services can contribute to better patient care in a triage context. Practical steps suggested are protective equipment use, ensuring access to critical drugs (such as opioids), greater use of telemedicine consultations, discussing advance care plans, and embracing the role of a wider community support.

End-of-Life Care Challenges from Staff Viewpoints in Emergency Departments: Systematic Review

The hospital emergency department (ED) is the place where people most commonly seek urgent care. The initial diagnosis of an end-of-life (EOL) condition may occur in the ED. In this review we described the challenges; from the staff members’ perspectives, to safe, appropriate, and high quality end-of-life care (EOLC) for people who are diagnosed with non-malignant diseases who present to ED settings internationally. We conducted a systematic review of peer-reviewed literature. PubMed, Scopus, CINAHL, Medline, and Web of Science were searched from 2007 to 2017. In this review the challenges in providing quality EOLC from staff viewpoints, for EOL people who are diagnosed with non-malignant progressive diseases in ED settings, were classified into eight themes: (1) EOLC education and training, (2) ED design, (3) Lack of family support, (4) Work Load, (5) ED staff communication and decision making, (6) EOLC quality in ED, (7) resource availability (time, space, appropriate interdisciplinary personnel) and (8) integrating palliative care (PC) in ED. The formulation of EOLC using this review result may help to improve the quality of life for dying people by providing ED staff with clear guidelines that can guide them in their daily practice

Paramedics providing palliative care at home: A mixed-methods exploration of patient and family satisfaction and paramedic comfort and confidence

OBJECTIVE

Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.

METHODS

In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.

RESULTS

In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = &lt; 0.001) as did confidence in palliative care without transport (p = &lt; 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.

CONCLUSIONS

After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

Emergency Department Use among End-Of-Life Home Care Clients

Emergency department (ED) use is a quality-of-care indicator for community-based end-of-life (EOL) care. This study examined ED use by EOL home care clients. The sample included all EOL home care clients who received care from one community care access centre in Ontario, Canada. Information on health was gathered using the interRAI instrument for palliative care. Data were collected between May 2009 and January 2010. The sample included 93 home care clients. Results showed that 35 percent of clients used the ED within 45 days of assessment. Multivariate analysis identified two determinants of ED use: excessive weight loss and previous hospitalization. Managing terminal illness is often a difficult task, and comprehensive, ongoing assessment of clients’ changing status is critical. Client care and service planning for clients who have lost excessive amounts of weight or who have been recently hospitalized need to be monitored closely to prevent any future avoidable ED use.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework

OBJECTIVES

Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM.

METHODS

The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine.

RESULTS

The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators.

CONCLUSIONS

Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in Ontario

Moving from one care setting to another is common as death nears. Many concerns exist over these end-of-life (EOL) care setting transitions, including low-quality moves as mistakes and other mishaps can occur. Delayed or denied moves are also problematic, such as a move out of hospital for dying inpatients who want to spend their last hours or days at home. The aim of the study was to identify current issues or problems with care setting transitions during the last year of life as well as potential or actual solutions for these problems. A grounded theory analysis approach was used based on interviews with 38 key informants who represent a wide range of healthcare providers, healthcare managers, government representatives, lawyers, healthcare recipients and their family/friends across Ontario in 2016. Three interrelated themes were revealed: (a) communication complexities, (b) care planning and coordination gaps and (c) health system reform needs. Six solutions were highlighted, with these designed to prevent care setting transition issues and monitor care setting transitions for continued improvements.

"They Shouldn't Be Coming to the ED, Should They?": A Descriptive Service Evaluation of Why Patients With Palliative Care Needs Present to the Emergency Department

BACKGROUND

Patients with palliative care needs frequently attend the emergency department (ED). There is no international agreement on which patients are best cared for in the ED, compared to the primary care setting or direct admission to the hospital. This article presents the quantitative phase of a mixed-methods service evaluation, exploring the reasons why patients with palliative care needs present to the ED.

METHODS

This is a single-center, observational study including all patients under the care of a specialist palliative care team who presented to the ED over a 10-week period. Demographic and clinical data were collected from electronic health records.

RESULTS

A total of 105 patients made 112 presentations to the ED. The 2 most common presenting complaints were shortness of breath (35%) and pain (28%). Eighty-three percent of presentations required care in the ED according to a priori defined criteria. They either underwent urgent investigation or received immediate interventions that could not be delivered in another setting, were referred by a health-care professional, or were admitted.

CONCLUSIONS

Findings challenge the misconception that patients known to a palliative care team should be cared for outside the ED. The importance and necessity of the ED for patients in their last years of life has been highlighted, specifically in terms of managing acute, unpredictable crises. Future service provision should not be based solely on a patient's presenting complaint. Further qualitative research exploring patient perspective is required in order to explore the decision-making process that leads patients with palliative care needs to the ED.

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?

'They shouldn't be coming to the ED, should they?' A qualitative study of why patients with palliative care needs present to the emergency department

INTRODUCTION

Across the developed world, there are concerns about 'inappropriate' use of the emergency department (ED). Patients with palliative care needs frequently attend the ED. Previous studies define the 'reason' for presentation as the 'presenting symptom', which ignores the perspectives of service users. This paper addresses an acknowledged gap in the literature, which fails to examine the decision-making process that brings patients to the ED.

METHODS

In-depth narrative interviews were conducted with 7 patients (known to a specialist palliative care service and presenting to the ED during a 10-week period) and 2 informal caregivers. Analysis drew on 'Burden of Treatment Theory' to examine the meaning attributed by participants to their experience of serious acute illness, their capacity for action and the work required to access emergency care.

RESULTS

5 themes were identified about how and why emergency services were accessed: capacity for action, making sense of local services, making decisions to access emergency services, experience of emergency care and coping with change. All narratives captured concerns surrounding the complexity of services. Participants struggled to piece together the jigsaw of services, and were subsequently more likely to attend the ED. Differences between the ways that patients with chronic obstructive pulmonary disease and cancer accessed the ED were prominent.

CONCLUSIONS

Further work is needed to understand and respond to decisions leading patients with palliative care needs to the ED, particularly in the context of locally fragmented services, poor signposting and confusion about available healthcare. The perspectives of service users are essential in shaping emergency care.

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents

CONTEXT

Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life.

OBJECTIVES

To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life.

METHODS

We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent.

RESULTS

Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week.

CONCLUSION

Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life

BACKGROUND

Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas.

AIM

The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas.

DESIGN

Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures.

SETTING/PARTICIPANTS

The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer.

RESULTS

The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care.

CONCLUSION

Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

"We Are Strangers Walking Into Their Life-Changing Event": How Prehospital Providers Manage Emergency Calls at the End of Life

CONTEXT

Emergency 911 calls are often made when the end stage of an advanced illness is accompanied by alarming symptoms and substantial anxiety for family caregivers, particularly when an approaching death is not anticipated. How prehospital providers (paramedics and emergency medical technicians) manage emergency calls near death influences how and where people will die, if their end-of-life choices are upheld and how appropriately health care resources are used.

OBJECTIVES

The purpose of this study was to explore and describe how prehospital providers assess and manage end-of-life emergency calls.

METHODS

In-depth and in-person interviews were conducted with 43 prehospital providers. Interviews were audiotaped, transcribed, and entered into ATLAS.ti for data management and coding. Qualitative data analysis involved systematic and axial coding to identify and describe emergent themes.

RESULTS

Four themes illustrate the nature and dynamics of emergency end-of-life calls: 1) multifocal assessment (e.g., of the patient, family, and environment), 2) family responses (e.g., emotional, behavioral), 3) conflicts (e.g., missing do-not-resuscitate order, patient-family conflicts), and 4) management of the dying process (e.g., family witnessed resuscitation or asking family to leave, decisions about hospital transport). After a rapid comprehensive multifocal assessment, family responses and the existence of conflicts mediate decision making about possible interventions.

CONCLUSION

The importance of managing symptom crises and stress responses that accompany the dying process is particularly germane to quality care at life's end. The results suggest the importance of increasing prehospital providers' abilities to uphold advance directives and patients' end-of-life wishes while managing family emotions near death.

What is the incidence of patients with palliative care needs presenting to the Emergency Department? a critical review

BACKGROUND

Given the context of ageing populations globally, there are a growing number of patients with chronic conditions, some of whom are in the final stages of their disease trajectory, presenting to Emergency Departments.

AIM

The aim was to estimate the incidence of patients with palliative care needs presenting to the department.

METHODS

Three databases (MEDLINE, CINAHL and Embase) were systematically searched up to August 2012. The reference lists of included articles were searched as well as Google and Google Scholar. Only studies in English were included. Two reviewers independently reviewed studies at the abstract and full-body stages. A critical review using systematic methods was undertaken as statistical analysis could not be done because of a lack of information.

RESULTS

Only 10 of 1427 identified records met the inclusion criteria. Different definitions of palliative care were evident. One article provided an incidence density for patients with non-small cell lung cancer, and we calculated the mean presentations to be 52.5 per 100 person-months. Two articles focussed on patients known to palliative care services; we estimated that 2.5 in 1000 Emergency Department visits were made by these patients. The review demonstrated that the studies were so different it was not possible to compare the data.

CONCLUSION

There is an absence of evidence regarding the incidence of patients with palliative care needs presenting to the Emergency Department. Further research needs to be undertaken in this area to ensure both clinicians and policymakers have sufficient information for service provision.

Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study

BACKGROUND

Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients.

METHODS

A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH.

RESULTS

Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55).

CONCLUSIONS

Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.

Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians

BACKGROUND

Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department.

OBJECTIVE

To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls.

DESIGN

This descriptive study used a cross-sectional survey design with mixed methods.

SETTING/PARTICIPANTS

One hundred seventy-eight prehospital providers (76 EMT-basics and 102 paramedics) from an emergency medical services agency participated.

MEASUREMENTS

Multiple choice and open-ended survey questions addressed how they learned about EOL calls, their confidence with advance directives, and perspectives on improving care in the field.

RESULTS

The response rate was 86%. Education about do-not-resuscitate (DNR) orders was formal (92%), experiential (77%), and self-directed (38%). Education about medical orders for life-sustaining treatment (MOLST) was formal (72%), experiential (67%), and self-directed (25%). Ninety-three percent were confident in upholding a DNR order, 87% were confident interpreting MOLST, and 87% were confident sorting out conflict between differing patient and family wishes. Qualitative data analysis yielded six themes on improving preparation of prehospital providers for EOL calls: (1) prehospital provider education; (2) public education; (3) educating health care providers on scope of practice; (4) conflict resolution skills; (5) handling emotional families; and (6) clarification of transfer protocols.

CONCLUSION

These study results suggest the need for addressing the potential interrelationship between prehospital and EOL care through improved education and protocols for care in the field.

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.

Research priorities for palliative and end-of-life care in the emergency setting

Palliative care focuses on the physical, spiritual, psychological, and social care from diagnosis to cure or death of a potentially life-threatening illness. When cure is not attainable and end of life approaches, the intensity of palliative care is enhanced to deliver the highest quality care experience. The emergency department (ED) frequently cares for patients and families during the end-of-life phase of the palliative care continuum. The intersection between palliative care and emergency care continues to be more clearly defined. Currently, there is a mounting body of evidence to guide the most effective strategies for improving palliative and end-of-life care in the ED. In a workgroup session at the 2009 Agency for Healthcare Research and Quality (AHRQ)/American College of Emergency Physicians (ACEP) conference "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach," four key research questions arose: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency clinicians in caring for patients along a chronic trajectory of illness, 3) how does the integration and initiation of palliative care training and services in the ED setting affect health care utilization, and 4) what are the educational priorities for emergency clinical providers in the domain of palliative care? Workgroup leaders suggest that these four key questions may be answered by strengthening the evidence using six categories of inquiry: descriptive, attitudinal, screening, outcomes, resource allocation, and education of clinicians.

Palliative care symptom assessment for patients with cancer in the emergency department: validation of the Screen for Palliative and End-of-life care needs in the Emergency Department instrument

OBJECTIVE

We sought to develop and validate a novel palliative medicine needs assessment tool for patients with cancer in the emergency department.

METHODS

An expert panel trained in palliative medicine and emergency medicine reviewed and adapted a general palliative medicine symptom assessment tool, the Needs at the End-of-Life Screening Tool. From this adaptation a new 13-question instrument was derived, collectively referred to as the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED). A database of 86 validated symptom assessment tools available from the palliative medicine literature, totaling 3011 questions, were then reviewed to identify validated test items most similar to the 13 items of SPEED; a total of 107 related questions from the database were identified. Minor adaptations of questions were made for standardization to a uniform 10-point Likert scale. The 107 items, along with the 13 SPEED items were randomly ordered to create a single survey of 120 items. The 120-item survey was administered by trained staff to all patients with cancer who met inclusion criteria (age over 21 years, English-speaking, capacity to provide informed consent) who presented to a large urban academic emergency department between 8:00 am and 11:00 pm over a 10-week period. Data were analyzed to determine the degree of correlation between SPEED items and the related 107 selected items from previously validated tools.

RESULTS

A total of 53 subjects were enrolled, of which 49 (92%) completed the survey in its entirety. Fifty-three percent of subjects were male, age range was 24-88 years, and the most common cancer diagnoses were breast, colon, and lung. Cronbach coefficient α for the SPEED items ranged from 0.716 to 0.991, indicating their high scale reliability. Correlations between the SPEED scales and related assessment tools previously validated in other settings were high and statistically significant.

CONCLUSION

The SPEED instrument demonstrates reliability and validity for screening for palliative care needs of patients with cancer presenting to the emergency department.

Palliative ultrasound for home care hospice patients

The evolving relationship between emergency and palliative medicine is expected to benefit patients of each. Two collaborative care encounters involving home hospice patients are discussed. Portable bedside ultrasound was performed in the home to diagnose ascites and to guide palliative paracentesis. Specific interventions and outcomes are reported. The interface of emergency and palliative care and the use of paracentesis in cancer palliation are briefly reviewed. It is concluded that home-performed ultrasound and ultrasound-guided procedures are promising palliative modalities for care at the end of life.

Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients?

PURPOSE

Fewer emergency department (ED) visits may be a potential indicator of quality of care during the end of life. Receipt of palliative care, such as that offered by the adult Palliative Care Service (PCS) in Halifax, Nova Scotia, is associated with reduced ED visits. In June 2004, an integrated service model was introduced into the Halifax PCS with the objective of improving outcomes and enhancing care provider coordination and communication. The purpose of this study was to explore temporal trends in ED visits among PCS patients before and after integrated service model implementation.

METHODS

PCS and ED visit data were utilized in this secondary data analysis. Subjects included all adult patients enrolled in the Halifax PCS between January 1, 1999 and December 31, 2005, who had died during this period (N = 3221). Temporal trends in ED utilization were evaluated dichotomously as preintegration or postintegration of the new service model and across 6-month time blocks. Adjustments for patient characteristics were performed using multivariate logistic regression.

RESULTS

Fewer patients (29%) made at least one ED visit postintegration compared to the preintegration time period (36%, p < 0.001). Following adjustments, PCS patients enrolled postintegration were 20% less likely to have made at least one ED visit than those enrolled preintegration (adjusted OR 0.8; 95% confidence interval 0.6-1.0).

CONCLUSION

There is some evidence to suggest the introduction of the integrated service model has resulted in a decline in ED visits among PCS patients. Further research is needed to evaluate whether the observed reduction persists.