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

Reasons to Access the Emergency Department by Patients Who Receive Palliative Home Care: A Scoping Review

BACKGROUND

The progressive aging of society has increased the prevalence of chronic, incurable diseases, creating a critical need for palliative care programs. Palliative home care services are essential for patients facing severe symptoms and barriers to accessing health care facilities. Despite this, many patients receiving palliative home care services still access emergency departments (EDs).

OBJECTIVES

This scoping review aimed to investigate ED visits among patients under palliative home care services, examining factors influencing access, patient characteristics, and leading reasons for ED visits.

METHODS

A scoping review was conducted by performing a systematic search of Scopus, PubMed, CINAHL, and PsycINFO between 2013 and 2024. Studies focusing on emergency access among adult patients older than 18 years cared for by a palliative home care service were included.

RESULTS

Eight retrospective studies across Italy, China, Canada, Australia, and Ireland were included. The studies revealed significant variability in ED visit rates, ranging from 8.6% to 69.15%, with cancer as the predominant diagnosis among patients. Dyspnea, pain, and fever were commonly cited reasons for ED visits, indicating potential gaps in symptom management at home.

DISCUSSION

The review highlights the importance of early enrollment in palliative home care services, multidisciplinary care, and better caregiver education to reduce unnecessary ED visits. The findings underscore the need for further research on predictive factors, avoidable versus unavoidable ED visits, and strategies for optimizing home-based palliative care to enhance patient outcomes and quality of life.

The Necessity of Palliative Care Interventions in Emergency Departments: A Literature Review

Palliative care, a beacon of relief and comfort, ensures the best quality of life for patients nearing death, a patient population that often presents to emergency departments, by providing interventions to promote comfort and support final wishes. The purpose of this literature review was to examine the outcomes of palliative care interventions for adult patients with chronic illnesses who have died in emergency departments. The literature review was conducted in CINAHL, PubMed, SCOPUS, OVID, and APA Psych using the keywords "palliative," "emergency department," "adult," and "chronic disease." The search was limited to English language publications with no date limits and performed according to Preferred Reporting Items for Systematic reviews and Meta-Analysis statement standards. The search yielded 531 articles, with 226 duplicates excluded. After a review, only 16 articles met the inclusion criteria. Common interventions included implementing screening tools, enhancing communication skills, providing end-of-life care education, and health record alerts for palliative care criteria. This review highlights how critical palliative care interventions are needed in emergency departments. The inevitability of seriously ill patients presenting to emergency departments underscores the urgency and importance of palliative care interventions, leading to increased comfort and decreasing distressing symptoms experienced by dying patients.

Prognostic factors and development of the practical prediction score for 7-day mortality of palliative patients in the emergency department

Background End-of-life (EOL) care aims to facilitate good death and fulfill the patient's final desires. Despite the known benefits of palliative consultations, emergency physicians encounter challenges in decision-making due to limited palliative resources. Previous studies primarily focus on non-emergency settings; thus, we aimed to develop a practical prediction score for 7-day mortality for palliative patients in the emergency department (ED). Methods This retrospective cohort study, conducted at a tertiary-level university hospital in Thailand between June 2022 and May 2023, evaluated adult palliative patients who declined life-sustaining treatments. Variables associated with 7-day mortality were analyzed using univariable and multivariable logistic regression. Results Of 499 ED visits, 152 patients (30.46%) died within seven days. Six predictors were identified: solid malignancy, respiratory with mandibular movement, systolic blood pressure < 100 mmHg, lymphopenia, thrombocytopenia, and a blood urea nitrogen to creatinine ratio > 20. These factors were used to develop the Ramathibodi End-of-life (RAMA-EOL) score, demonstrating an AuROC curve of 80.46% (95% CI: 76.15-84.77). Patients with a score ≥ 3 had a positive likelihood ratio of 2.92 (95% CI: 2.38-3.57) for 7-day mortality. Conclusion The RAMA-EOL score reliably predicts 7-day mortality in palliative ED patients, facilitating timely palliative care interventions for high-risk individuals.

Palliative care in the public health system: how do physicians deal with their patients at the end of life?

BACKGROUND

Patients with cancer are referred late to palliative care services (PCS).

AIM

To analyse the time of referral to PCSs and the characteristics of patients that are referred.

METHODS

A retrospective cohort. All patients admitted in a single tertiary care institution were evaluated by the PCSs from February 1, 2018 to January 31, 2019.

FINDINGS

Among the 642 patients (557 patients with cancer) referred to PCSs: 7.47% died before evaluation, 13.08% died before transfer, and 15.6% died within 8 days after transfer. Out of all the patients with cancer included in the study, 85.28% had less than 2 months of PCS follow-up during their disease. In the last 30 days of life, 96.26% had were readmitted to hospital. A total of 94.09% of patients with cancer died in a hospital.

CONCLUSION

These findings suggest that patients with cancer in Brazil are not referred early enough to PCSs. Early integration with PCS must be sought to improve the accuracy of referral.

Outcomes of Specialist Palliative Care Consultation for Patients with Advanced Cancer in an Oncological Emergency Department: A Retrospective Analysis

Objectives

Research on palliative care (PC) consultation and its outcomes in the emergency department (ED) within a low-and middle-income country (LMIC) setting is limited. This study aimed to evaluate PC consultation outcomes, symptom burden and management, and referral patterns in patients with advanced cancer referred for specialist PC (SPC) in the ED of an urban tertiary care cancer centre in India.

Materials and Methods

Data of adult advanced cancer patients referred for SPC services in the ED between August 2017 and June 2019 were retrospectively screened. Patients' sociodemographic features, clinical characteristics, ED visit-related data, and treatment-related data were documented. Multinomial logistic regression, incorporating significant univariate factors, was performed to analyse the independent predictive factors of consultation outcomes in the ED.

Results

Of the 644 consultations, 366 (56.8%) were discharged home, 166 (25.8%) were admitted to various settings (hospital/respite care/hospice), 74 (11.5%) died in the ED, and 38 (5.9%) were unresponsive upon arrival. Sex, performance status (PS), gastrointestinal and cardiovascular events, pain, cancer progression, and receipt of pharmacological treatment were predictive of consultation outcomes. Male patients and those with poor PS were more likely to be admitted to the ED, whereas patients with poor PS and cancer progression were more likely to die. Discharge rates were higher among females, those with gastrointestinal symptoms and pain, and those receiving pharmacological treatment.

Conclusion

More than 50% of the patients referred for SPC consultations were discharged. In addition, we also identified predictors for each consultation outcome in the LMIC-ED setting. Future research should investigate advanced care planning and survival analyses in comparable ED settings.

Pattern of admissions and needs assessment for palliative care services among in-patients in a tertiary health facility in South-Western Nigeria

BACKGROUND

Palliative care evolution focuses on education and medication accessibility. As little as 12% of palliative care needs are met. Assessment of the domains of Palliative care and patients' and families' experience are essential in life-limiting conditions. The Lagos University Teaching Hospital (LUTH), have the National Cancer Centre without offering palliative care services.

AIM

The aim was to examine pattern of admissions and needs assessment for palliative services among patients admitted into LUTH wards.

MATERIALS AND METHOD

Responses were entered into a data sheet inputted into Epi info version 7.2. Descriptive characteristics of the participants were presented as frequencies and percentages for age, sex, pattern of disease, domains of Palliative care, Advance care Plan, Preparation for home care, death and Education about the illness and category of medical conditions (palliative and non-palliative conditions). Together for Short Lives (TfSL) tool was used to categorize respondents' conditions into Palliative and Non-palliative conditions. Chi-square test was used to determine association between independent variables (pattern of diagnoses, stage of disease, advanced care plan, preparation for home care/ death and education on illness) and dependent variables (category of medical condition). Chi-square test was also used to explore the association between specialty of the managing doctor (independent variable) and Advance care plan (dependent variable). The level of statistical significance was P-value < 0.05.

RESULTS

80.6% of the respondents had palliative care conditions, 83.7% had family members as their caregiver while 13.2% of the participants had no caregiver and 65.9% had no advance care plan. There was no preparation for home care or death in 72.1%, 70.5% had education about their illness, and 68.2% were in the advanced stage of their disease. Participants attending the surgery non-trauma unit (51.6%) were more likely to have advance care plans. Adults were more likely to have palliative care conditions (79.8%) compared to children (20.2%), and was statistically significant.

CONCLUSION

Majority of the participants need palliative care services but are unavailable and unmet and the most predominant condition was cancer. Majority had no advance care plan or preparation for home care or death despite having advanced stage of the disease. This survey emphasized the need for symptom management, communication and provision of support.

Missed Opportunity to Diagnose Palliative Care Need Among Older Emergency Department Patients in a Middle-Income Country: A Retrospective Study

Purpose

This study aimed to determine the percentage of missed opportunities (MOs) to identify and treat older adults presenting with palliative care (PC) needs at one emergency department (ED). The secondary objective was to determine the rate of treatment interventions regardless of whether the patients received a PC plan as well as the direct cost of treatment.

Patients and Methods

In this retrospective study, PC need was determined using broad and narrow criteria. The subjects comprised patients aged 65 or older who had out-of-hospital cardiac arrest and/or died in the ED (Group 1) or within 72 hours after ED disposition (Group 2) over a 3-year period (2016-2018). Overall, 17,414 older adults visited the ED, 60 died in the ED, and 400 died within 72 hours after ED disposition and admitted to in-hospital ward. In total, 200 patients were randomly selected; of these, 15 were excluded.

Results

Of the remaining 185 patients enrolled, 161/185 (87%) met the PC criteria and 60/161 (37.3%) were missed opportunities for PC planning. Group 1, had thirty patients, and 8 of those 30 (27%) were missed opportunities for PC planning. Group 2, 131/161 (81.4%), died within 72 hours, and there were 52 missed opportunities (39.7%) of ED PC planning. By comorbidity (Group 2), providers considered PC planning most often for cancer patients (PC: 41.8%; missed opportunities: 15.4%; p = 0.001) and there were more missed opportunities for PC planning among those with ischemic heart disease (PC: 19.0%; missed opportunities: 36.5%; p = 0.025).

Conclusion

Of the older adults who visited the ED, 87% merited palliative care; further, 37% of opportunities for PC planning were missed. Providers considered PC planning most often for cancer patients. Recognizing PC needs and initiating care in the ED can improve end-of-life quality for dying patients.

A study of the factors associated with emergency department visits in advanced cancer patients receiving palliative care

Purpose

Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients.

Methods

A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16–100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value < 0.15 from the univariate logistic regression analysis were included in the multiple logistic regression analysis.

Results

Among a total of 227 patients, 93 visited the ED and 134 did not. Mean age was 65.5 years. Most prevalent cancers were colorectal (18.5%), lung (16.3%), and hepatobiliary (11.9%). At the end, 146 patients died, 45 were alive, nine were referred to other programs, and 27 were lost to follow-up. In univariate logistic regression analysis, patients with > 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p-value 0.01) were less likely to attend the ED. In contrast, PPS 50–90% (OR 2.02; 95%CI 1.18, 3.47; p-value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p-value 0.01) and PPS 50–90% (OR 2.62; 95%CI 1.44, 4.79; p-value 0.01).

Conclusions

There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.