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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A study to improve communication between clinicians and patients with advanced heart failure: methods and challenges behind the working to improve discussions about defibrillator management trial

We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.

Disparities in hospitalized cancer patients receiving palliative care consultation

7

Background: Racial and ethnic disparities in healthcare have been well documented among minority groups with respect to access to care, receipt of care, and quality of care. As a result, minority populations are diagnosed with late stage cancer and have inferior outcomes likely leading to increased suffering. Little is known, however, about disparities in access to and outcomes of patients receiving specialty palliative care (PC). Methods: We used data from the Palliative Care for Cancer Patients (PC4C) study, a multisite observational study of the effect of inpatient PC on patient health outcomes and health services use among advanced cancer patients. We limited our sample to patients that received PC from established, interdisciplinary consult teams. We used univariate analyses and multiple regression analyses to compare differences in outcomes among minority (black and Hispanic) and non-minority patients receiving PC. Results: 583 (19%) patients received a PC consult. Of those, 166 (28%) were minorities and 418 (72%) non-minorities. Mean days to a palliative care consult was 4.4 vs. 3.2 in non-minorities and minorities, respectively (p=0.65). At baseline, minority patients reported a higher burden of symptoms as measured by the condensed memorial symptom assessment scale (CMSAS). Similarly, they were less likely to have talked about their wishes with their doctor (p=0.04); less likely to have completed a living will (p<0.001), or have a proxy (p<0.001); had no difference in pain but were less likely to be taking pain medications (p<0.001) or report relief from pain medicines (p=0.05). After PC consult all CMSAS symptoms improved for minority patients (except worry; p=0.03). Additionally, after PC consult there were no longer any significant differences among minorities with respect to discussing their wishes (p=0.27), DNR completion (p=0.72), proxy assignment (p=0.22) and taking pain medications (p=0.22) when compared to non-minorities. Conclusions: PC is associated with improvements in symptom control and discussions of care goals among minority patients who have worse baseline health assessments. Future efforts need to focus on increasing the availability and use of specialty PC for this at-risk population.

Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research

BACKGROUND

Maintaining the recent expansion of palliative care access in the United States is a recognized public health concern. Economic evaluation is essential to validate current provision and assess the case for new programs. Previous economic reviews in palliative care reported on programs across settings and systems; none has examined specifically the hospital consultative model, the dominant model of provision in the United States.

OBJECTIVES

To review systematically the economic evidence on specialist palliative care consultation teams in the hospital setting, to appraise this evidence critically, and to identify areas for future research in this field.

DATA SOURCES

A meta-review ("a review of existing reviews") was conducted of eight published systematic reviews and one relevant nonsystematic review. To identify articles published outside of the timeframe of these reviews, systematic searches were performed on the PubMed, CINAHL, and EconLit databases.

STUDY SELECTION

Articles were included if they compared the costs and/or cost effectiveness of a specialist hospital inpatient palliative care consultation for adult patients with those of a comparator.

RESULTS

Ten studies were included and these demonstrate a clear pattern of cost-saving impact from inpatient consultation programs. Nevertheless, knowledge gaps still exist regarding the economic effects of these programs. Current evidence has been generated from the hospital perspective; health system costs, patient and caregiver costs, and health outcomes are typically not included.

CONCLUSIONS

Inpatient palliative care consultation programs have been shown to save hospitals money and to provide improved care to patients with serious illness. With a clear pattern of cost-saving using current methodology, it is timely to begin expanding the scope of economic evaluation in this field. Future research must address the measurement of both costs and outcomes to understand more fully the role that palliative care plays in enhancing value in health care. Relevant domains for such research are identified.

Emergency department-initiated palliative care for advanced cancer patients: protocol for a pilot randomized controlled trial

Background

For patients with advanced cancer, visits to the emergency department (ED) are common. Such patients present to the ED with a specific profile of palliative care needs, including burdensome symptoms such as pain, dyspnea, or vomiting that cannot be controlled in other settings and a lack of well-defined goals of care. The goals of this study are: i) to test the feasibility of recruiting, enrolling, and randomizing patients with serious illness in the ED; and ii) to evaluate the impact of ED-initiated palliative care on health care utilization, quality of life, and survival.

Methods/Design

This is a protocol for a single center parallel, two-arm randomized controlled trial in ED patients with metastatic solid tumors comparing ED-initiated palliative care referral to a control group receiving usual care. We plan to enroll 125 to 150 ED-advanced cancer patients at Mount Sinai Hospital in New York, USA, who meet the following criteria: i) pass a brief cognitive screen; ii) speak fluent English or Spanish; and iii) have never been seen by palliative care. We will use balanced block randomization in groups of 50 to assign patients to the intervention or control group after completion of a baseline questionnaire. All research staff performing assessment or analysis will be blinded to patient assignment. We will measure the impact of the palliative care intervention on the following outcomes: i) timing and rate of palliative care consultation; ii) quality of life and depression at 12 weeks, measured using the FACT-G and PHQ-9; iii) health care utilization; and iv) length of survival. The primary analysis will be based on intention-to-treat.

Discussion

This pilot randomized controlled trial will test the feasibility of recruiting, enrolling, and randomizing patients with advanced cancer in the ED, and provide a preliminary estimate of the impact of palliative care referral on health care utilization, quality of life, and survival.

Trial registration

Clinical Trials.gov identifier: NCT01358110 (Entered 5/19/2011).

Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers

PURPOSE

Research has shown that patients with terminal illnesses prefer to die at home, yet more than 60% of patients with cancer are hospitalized in the last month of life. Less than half of these patients receive hospice care at the end of life. Inpatient palliative care consultations may serve as a bridge from hospitalization to receiving patient's preferred end-of-life care. GI tumors include some the deadliest cancers, and patients with these cancers may serve to benefit from palliative care services.

METHODS

The objective of this study was to evaluate the role of palliative care versus usual care on postdischarge outcomes and hospice use for patients with advanced GI cancers. Two hundred one adults, 82 of whom received a palliative care consult, were followed for 6 months after hospital discharge. Propensity scores were used to match palliative care patients to usual care patients. Outcome measures included hospice use, place of death, subsequent emergency department visits, hospital readmission, and survival.

RESULTS

Fifty-nine patients died in the 6 months postdischarge. Receiving a palliative care consult increased the odds of home death (odds ratio [OR] = 2.9; 95% CI, 1.02 to 8.44; P = .046) and decreased the odds of hospital death (OR = 0.159; 95% CI, 0.05 to 0.52; P = .002). At 2 and 4 months, more patients in the palliative care group were receiving hospice services at death, compared with the usual care group (75% v 18%, P = .001% and 93% v 30%, P = .000 respectively). There were no differences with respect to emergency department visits, hospital readmission, and survival.

CONCLUSION

Palliative care consultation was associated with increased hospice utilization, decreased likelihood of dying in a hospital, and increased likelihood of dying at home.

Methods for constructing and assessing propensity scores

OBJECTIVES

To model the steps involved in preparing for and carrying out propensity score analyses by providing step-by-step guidance and Stata code applied to an empirical dataset.

STUDY DESIGN

Guidance, Stata code, and empirical examples are given to illustrate (1) the process of choosing variables to include in the propensity score; (2) balance of propensity score across treatment and comparison groups; (3) balance of covariates across treatment and comparison groups within blocks of the propensity score; (4) choice of matching and weighting strategies; (5) balance of covariates after matching or weighting the sample; and (6) interpretation of treatment effect estimates.

EMPIRICAL APPLICATION

We use data from the Palliative Care for Cancer Patients (PC4C) study, a multisite observational study of the effect of inpatient palliative care on patient health outcomes and health services use, to illustrate the development and use of a propensity score.

CONCLUSIONS

Propensity scores are one useful tool for accounting for observed differences between treated and comparison groups. Careful testing of propensity scores is required before using them to estimate treatment effects.

National hospice survey results: for-profit status, community engagement, and service

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P &lt; .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay

Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.

Evaluating the role of palliative care consultations in patients with advanced gastrointestinal cancers

6

Background: Though research shows that patients with terminal illnesses prefer to die at home, over 60% of patients with advanced cancer are hospitalized in the last month of life. Additionally, less than half of these patients receive any form of hospice care at the end of life, despite its demonstrated potential to improve quality of care. Inpatient palliative care (PC) consultations may serve as a bridge from hospitalization to receiving the kind of end-of-life care that patients prefer. Tumors of the gastrointestinal (GI) system include some of the most common and deadliest cancers and these patients can benefit from PC services, especially when the disease has reached an advanced stage. Our objective was to compare the effectiveness of inpatient PC consultations vs. usual care on post-discharge outcomes in patients with advanced GI cancers. Methods: 202 adults with advanced GI cancers admitted to 5 US hospitals were followed prospectively through hospitalization and 6 months post-discharge. 82 patients received a palliative care consult during hospitalization. Propensity scores were used to match treated to control patients, with exposure to a palliative care consult as the intervention. Outcome measures included: referral to hospice, subsequent ER visit, hospital readmission, and place of death. Results: Significantly more patients in the treatment group were referred to hospice upon hospital discharge (38% vs. 8%, p=0.000). 70 patients died in the 6-month follow-up period. Receiving a PC consult increased the odds of dying at home 3-fold (OR=2.9, p=0.046, 95% CI 1.02-8.44) and decreased the odds of dying in a hospital by 85% (OR=0.159, p=0.002, 95% CI 0.05-0.52). At 2 and 6 months post-discharge, significantly more patients in the treatment group were receiving hospice services at death (75% vs. 18%, p=0.001 and 82% vs. 24%, p=0.000 respectively). There were no significant differences between the two groups regarding hospital readmission and ER visits post-discharge. Conclusions: PC consults for patients with advanced GI cancers was associated with increased referral to hospice, decreased likelihood of dying in a hospital and increased likelihood of dying at home.

Standardized criteria for required palliative care consultation on the solid tumor oncology service

37

Background: Studies have shown that routine integration of Palliative Care (PC) for patients with advanced cancer is associated with improved symptom control, clearer understanding of prognosis, lower utilization of health care resources, and increased hospice use. The 2012 ASCO guidelines call for incorporation of PC for any patient with metastatic cancer and/or high symptom burden. Despite a top-rated PC division at Mount Sinai, our Solid Tumor (ST) Division utilized PC and hospice less than other medical centers. Our inpatient ST service consistently demonstrated poor quality metrics. Our 2011-2012 UHC statistics were: mortality index, 1.35 (target <1), 30-day readmission rate, 21.7%, (target < 10.3%) and length of stay (LOS) index, 1.23 (target <1). We hypothesized that implementing standardized criteria for PC consultation would improve these metrics. Methods: During this 3-month pilot, criteria for PC consultation included patients with one or more of the following: stage IV disease, Stage III lung or pancreatic cancer, hospitalization within prior 30 days, >7 day hospitalization, uncontrolled symptoms (pain, nausea, dyspnea, delirium, distress). We looked at two baseline groups for comparison: 1) patients who met eligibility in a six week period prior to the intervention 2) For UHC index data, we used the hospital dashboard average over a 1-year period prior to the intervention. This included all ST patients who were eligible for the intervention (60%) and those who were not (40%). Primary outcomes were: hospice utilization, ST mortality index, 30-day readmission rate and LOS. Results: Comparing Group 1 to the Pilot Group, palliative care consultation doubled from 41% to 82%, 30-day readmission decreased from 36% to 17% (p= .022), and hospice utilization increased from 14% to 25% (p=.146). UHC data (Group 2 vs. Pilot) showed: mortality index improved (1.35 to .59) and 30-day readmission rates decreased (21.7% to 13.5%, p=.026). LOS was unchanged (1.23 to 1.25). Conclusions: Mandating palliative care consults for patients at the highest risk for in hospital death and readmission improved hospice utilization, 30-day readmission, oncology service mortality and adherence with ASCO guidelines.

Pain management in older adults

BACKGROUND

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

OBJECTIVE

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

METHODS

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

RESULTS

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

CONCLUSION

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Models of palliative care delivery in the United States

PURPOSE OF REVIEW

To summarize the current United States healthcare system and describe current models of palliative care delivery.

RECENT FINDINGS

Palliative care services in the USA have been heavily influenced by the public-private fee-for-service reimbursement system. Hospice provides care for 46% of adults at the end-of-life under the Medicare hospice benefit. Palliative care teams in hospitals have rapidly expanded to provide care for seriously ill patients irrespective of prognosis. To date, over two-thirds of all hospitals and over 85% of mid to large size hospitals report a palliative care team. With the passage of the Patient Protection and Affordable Care Act of 2010, healthcare reform provides an opportunity for new models of care.

SUMMARY

Palliative care services are well established within hospitals and hospice. Future work is needed to develop quality metrics, create care models that provide services in the community, and increase the palliative care workforce.

An update: NIH research funding for palliative medicine 2006 to 2010

BACKGROUND

Palliative care clinical and educational programs are expanding to meet the needs of seriously ill patients and their families. Multiple reports call for an enhanced palliative care evidence base.

OBJECTIVE

To examine current National Institutes of Health (NIH) funding of palliative medicine research and changes since our 2008 report.

METHODS

We sought to identify NIH funding of palliative medicine from 2006 to 2010 in two stages. First, we searched the NIH grants database RePorter for grants with key words "palliative care," "end-of-life care," "hospice," and "end of life." Second, we identified palliative care researchers likely to have secured NIH funding using three strategies: (1) We abstracted the first and last authors' names from original investigations published in major palliative medicine journals from 2008 to 2010; (2) we abstracted these names from a PubMed generated list of all original articles published in major medicine, nursing, and subspecialty journals using the above key words Medical Subject Headings (MESH) terms "palliative care," "end-of-life care," "hospice," and "end of life;" and (3) we identified editorial board members of palliative medicine journals and key members of palliative medicine research initiatives. We crossmatched the pooled names against NIH grants funded from 2006 to 2010.

RESULTS

The NIH RePorter search yielded 653 grants and the author search identified an additional 352 grants. Compared to 2001 to 2005, 589 (240%) more grants were NIH funded. The 391 grants categorized as relevant to palliative medicine represented 294 unique PIs, an increase of 185 (269%) NIH funded palliative medicine researchers. The NIH supported 21% of the 1253 original palliative medicine research articles identified. Compared to 2001 to 2005, the percentage of grants funded by institutes other than the National Cancer Institute (NCI), the National Institute for Nursing Research (NINR), and the National Institute of Aging (NIA) increased from 15% to 20% of all grants.

CONCLUSIONS

When compared to 2001-2005, more palliative medicine investigators received NIH funding; and research funding has improved. Nevertheless, additional initiatives to further support palliative care research are needed.

Palliative oncology: identity, progress, and the path ahead

Palliative care is a rapidly growing subspecialty of medicine entailing expert and active assessment, evaluation and treatment of the physical, psychological, social and spiritual needs of patients and families with serious illnesses. It provides an added layer of support to the patient's regular medical care. As cancer is detected earlier and its treatments improve, palliative care is increasingly playing a vital role in the oncology population. Because of these advances in oncology, the role of palliative care services for such patients is actively evolving. Herein, we will highlight emerging paradigms in palliative care and attempt to delineate key education, research and policy areas that lie ahead for the field of palliative oncology. Despite the critical need for improving multi-faceted and multi-specialty symptom management and patient-physician communication, we will focus on the interface between palliative care and oncology specialists, a relationship that can lead to better overall patient care on all of these levels.

Disability and decline in physical function associated with hospital use at end of life

BACKGROUND

Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.

OBJECTIVE

To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.

DESIGN/PARTICIPANTS

We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).

KEY RESULTS

Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).

CONCLUSIONS

Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

Characteristics of emergency department patients who receive a palliative care consultation

BACKGROUND

A large gap exists between the practice of emergency medicine and palliative care. Although hospice and palliative medicine has recently been recognized as a subspecialty of emergency medicine, few palliative care teams routinely interact with emergency providers, and primary palliative care skills among emergency providers are lacking.

OBJECTIVE

To identify the proportion and characteristics of patients who receive a palliative care consultation and arrive via the emergency department (ED).

METHODS

A descriptive study of adult ED patients from an urban, academic tertiary care hospital who received a palliative care consultation in January 2005 or January 2009.

RESULTS

In January 2005, 100 of the 161 consults (62%) arrived via the ED versus 63 of 124 consults (51%) in January 2009 (p=0.06). Mean days from admission to consultation in January 2005 were six days (standard deviation 11), versus nine days (SD 26) in January 2009 (p=0.35). Three of the 100 consultations (3%) in January 2005 were initiated in the ED, versus 4 of the 64 (6%) in January 2009.

CONCLUSIONS

At an urban academic medical center with a well-developed palliative care service, the majority of palliative care consultations were for patients who arrive via the ED. Despite this, only a small minority of consultations originated from emergency providers and consultation was on average initiated days into a patient's hospital stay.

Advanced dementia: state of the art and priorities for the next decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.