Palliative care needs of seriously ill, older adults presenting to the emergency department

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association

Introduction:

In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.

Methods:

We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers’ wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant.

Results:

The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD.

Conclusions:

The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

Characteristics and outcomes of "Do Not Resuscitate" patients admitted to the emergency department-Intensive care unit

BACKGROUND

Appropriate utilization of intensive care unit (ICU) beds are essential. Patients with critical illness who have do not resuscitate (DNR) have a reduced priority of intensive care. However, the possibility of recovery/survival is ambiguous and multifactorial.

OBJECTIVE

To deliberate the characteristics and outcomes of critical illness in patients with prior DNR who were admitted to the emergency department (ED)-ICU.

METHOD

This was a retrospective cohort study conducted between April 2015 and November 2015 in a university-based hospital. Non-traumatic patients with DNR admitted to ED-ICU from ED were included.

RESULTS

Seventy-eight non-trauma patients with prior DNR status were included in the final analysis. 51.3% (40/78) patients were male with median age 83 (IQR: 75-89) years. The median APACHE II score was 24.5 (IQR: 20-30). 50% (39/78) of the DNR patients survived to discharge. Patients who survived to discharge had lower APACHE II score (23 (IQR: 20-28) vs. 28 (18-38), p = 0.028). There was no significant difference in age, gender, and Charlson index. ROC curves were constructed, generating a cut-off of the APACHE II score at 29.5 for determining survival to discharge (AUC = 0.644, p = 0.028). In multivariate Cox proportional model, APACHE II score above 29.5 was an independent predictor for mortality. (Hazard ratio = 2.46; 95% confidence interval: 1.04-5.83, p = 0.042).

CONCLUSION

Our study found that 50% of patients with prior DNR on ICU admission survived to discharge, indicating that aggressive care is not definitely futile. Further prospective studies are required to evaluate the cost-effectiveness and patients' and/or families' satisfaction of the ICU admission of DNR patients.

The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study

BACKGROUND

Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients' perceptions of hospital Emergency Department presentations.

AIM

To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers.

DESIGN

Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame.

SETTING/PARTICIPANTS

In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed.

RESULTS

Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options.

CONCLUSION

Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Patients with End-stage Oncologic and Nononcologic Disease in Emergency Service of an Urban Tertiary Hospital

CONTEXT

In the last decades, patients with chronic terminal diseases have had more frequent visits to emergency services.

AIMS

This study aims to determine the proportion of terminal illness in patients readmitted to emergency room, to evaluate the use of this service and rate of death.

SETTINGS AND DESIGN

A cross-sectional study in a tertiary hospital with 120 stretchers which annually reports 160 thousand attentions and 22 thousand admissions.

SUBJECTS AND METHODS

Included 18-year-old patients or older who were readmitted to emergency room. Patient and/or caregiver were interviewed; medical record was reviewed and made 1-year follow-up. Terminal cancer was determined by histologically confirmation in Stage IV and nononcologic terminal disease by total functional dependence (Katz index) or severe cognitive impairment (Pfeiffer questionnaire) in addition of advanced organ failure.

STATISTICAL ANALYSIS USED

Fisher's exact and U of Mann-Whitney tests for two independent samples.

RESULTS

Ninety-two (26%) of 349 were readmissions; 29 (36.7%) of 79 evaluated patients were identifying with terminal disease. Eleven (38%) of them had cancer (genitourinary in 64%). Nononcologic terminal disease was identified in 18 cases (62%) (Neurodegenerative involvement in 50%). More frequent symptoms were dyspnea 41%, mental confusion 24%, and pain 21%. Terminal patients had 6.2 (standard deviation 8.2) emergency visits at last year, being admitted 48,6% of these visits. Six-month mortality rate was 73 and 61% in oncologic and nononcolgic patients, respectively (P < 0.05).

CONCLUSIONS

End-stage disease is frequent in readmitted patients to emergency, more of nononcologic kind. These patients use frequently emergency service, with high mortality (more elevated in oncologic).

Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review

BACKGROUND

Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions.

OBJECTIVES

To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes.

DESIGN

Systematic review.

STUDY SELECTION

English-language articles analyzing multicomponent palliative care interventions.

OUTCOMES MEASURED

Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life).

RESULTS

Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes.

CONCLUSIONS

While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.

Implementing a novel model for hospice and palliative care in the emergency department: An experience from a tertiary medical center in Taiwan

Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.

Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors

BACKGROUND

Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital.

METHODS

This population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001-2004), first strategy phase (2004-2008), and strategy intensification (2009-2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs).

RESULTS

Over 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004-2005, hospital deaths fell (PRs 0.92-0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01-1.55) than COPD (PRs 1.01-1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94-0.94) or outside London (PRs, 0.89-0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65-74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89-1.04); in COPD, hospital death was associated with being married.

CONCLUSIONS

The EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.

The Palliative Performance Scale Predicts Survival among Emergency Department Patients, Minia, Egypt

Background:

Emergency department (ED) physicians provide care to patients with a wide range of prognoses, and must develop care plans that anticipate patient's survival. However, the tools available to guide care planning had limited data to support their use. There is a new concern to understand if palliative care (PC) should be offered in the ED and the Palliative Performance Scale (PPS), a screening tool used in other settings in PC, has been little used in the ED.

Aim:

The aim of this study is to assess the prognostic value of the PPS in predicting 1, 3 and 6 months survival in patients admitted through the ED.

Design:

This was a prospective, cohort study.

Subjects and Methods:

We evaluated 147 patients at the age of 35 years and more admitted through the ED of Minia University hospital from May 1, 2016 to June 31, 2016. Each patient's PPS score was evaluated initially in the ED, with follow-up assessments of survival at 1, 3, and 6 months.

Results:

Baseline PPS for the 147 patients was 50. The PPS score was a strong predictor of survival (Log-rank test of Kaplan–Meir P < 0.0001). Patients with an initial PPS score of 40 or less were less likely to survive at 6 months.

Conclusion:

The PPS score may predict survival in patients admitted to the hospital through the ED. The ease of use holds promise that the use of the PPS in the ED may help ED physicians predict survival and plan for a better decision.

Death among elderly patients in the emergency department: a needs assessment for end-of-life care

INTRODUCTION

Elderly patients with serious chronic diseases often present to the emergency department (ED) in the last moments of their life, many with identifiable trajectories of dying: organ failure, advanced cancer and chronic frailty. These patients and their families may benefit more from good end-of-life (EOL) care provision than the standard resuscitative approach. This study aimed to determine the incidence and nature of death among patients aged ≥ 65 years in an ED, and characterise their trajectories of dying.

METHODS

This was a retrospective study carried out over a one-year period in a tertiary ED. All ED deaths in patients aged ≥ 65 years over this period were included. Information on the patients' demographics, comorbidities and details of death were extracted from the hospital's electronic medical records database. Based on the available information, their Karnofsky Performance Status (KPS) scores and trajectories of dying were ascertained.

RESULTS

In one year, 197 patients aged ≥ 65 years died in the ED, 51.3% of whom suffered from serious chronic illnesses, with identifiable trajectories of dying. Of these patients, 46.5% had premorbid functional limitation with KPS scores of 0-40. However, only 14.9% of patients had a pre-existing resuscitation status and 74.3% received aggressive resuscitative measures.

CONCLUSION

There is a significant burden of EOL care needs among elderly patients in the ED. Many of these patients have chronic illness trajectories of dying. This study underscores the need for improvement in EOL care provision for dying patients and their families in the ED.

The Emergency Care of Patients With Cancer: Setting the Research Agenda

To identify research priorities and appropriate resources and to establish the infrastructure required to address the emergency care of patients with cancer, the National Institutes of Health's National Cancer Institute and the Office of Emergency Care Research sponsored a one-day workshop, "Cancer and Emergency Medicine: Setting the Research Agenda," in March 2015 in Bethesda, MD. Participants included leading researchers and clinicians in the fields of oncology, emergency medicine, and palliative care, and representatives from the National Institutes of Health. Attendees were charged with identifying research opportunities and priorities to advance the understanding of the emergency care of cancer patients. Recommendations were made in 4 areas: the collection of epidemiologic data, care of the patient with febrile neutropenia, acute events such as dyspnea, and palliative care in the emergency department setting.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A prospective cohort study.

SETTING/SUBJECTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Evaluation of the symptoms and treatment prescribed to hospitalized patients

OBJECTIVE

Evaluation of the presence of symptoms and suitability in the treatment of patients admitted to medical wards at HU-UFSC. Identification of patients eligible for palliative care (PC).

METHOD

A prospective cohort study, which evaluated patients in the first 48 hours of hospitalization (D1) and after 48 hours (D2). On D1, palliative performance and symptom assessment scales were applied (PPS/ESAS). The treatment established for the control of detected symptoms was also identified. On D2, the ESAS scale was applied again, and the medical prescription reviewed. When the presence of severe symptoms was found, the attending physician was informed. Patients who presented PPS≤60 were eligible for PC prioritization. For statistical analysis Student's t and χ2 tests were used.

RESULTS

168 patients were studied. Of these, 26.8% had PPS≤60. PC was described in one medical chart. Patients with mild symptoms reported significant worsening in the second evaluation, especially worsening in pain (32.3%) and well-being (49.3%). Symptoms considered severe showed significant improvement. There was no control of pain reported as moderate. Prescriptions for pain control were predominantly "if necessary", prevailing the use of non-opioid analgesics and weak opioids. The attending physician was informed of 116 (69%) patients with ESAS score≥4.

CONCLUSION

The control of symptoms, especially those considered mild, was unsatisfactory. Drug prescription was inadequate to control pain, and non-existent for some reported symptoms. There was no adequate prioritization of PC. There is a need for optimization and dissemination of PC among health professionals.

Cancer patients, emergencies service and provision of palliative care

SUMMARY Objective: To describe the clinical and sociodemographic profile of cancer patients admitted to the Emergency Center for High Complexity Oncologic Assistance, observing the coverage of palliative and home care. Method: Cross sectional study including adult cancer patients admitted to the emergency service (September-December/2011) with a minimum length of hospital stay of two hours. Student’s t-test and Pearson chi-square test were used to compare the means. Results: 191 patients were enrolled, 47.6% elderly, 64.4% women, 75.4% from the city of Recife and greater area. The symptom prevalent at admission was pain (46.6%). 4.2% of patients were linked to palliative care and 2.1% to home care. The most prevalent cancers: cervix (18.3%), breast (13.6%) and prostate (10.5%); 70.7% were in advanced stages (IV, 47.1%); 39.4% without any cancer therapy. Conclusion: Patients sought the emergency service on account of pain, probably due to the incipient coverage of palliative and home care. These actions should be included to oncologic therapy as soon as possible to minimize the suffering of the patient/family and integrate the skills of oncologists and emergency professionals.

Emergency Department-Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial

IMPORTANCE

The delivery of palliative care is not standard of care within most emergency departments (EDs).

OBJECTIVE

To compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization.

INTERVENTIONS

Intervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care.

MAIN OUTCOMES AND MEASURES

The primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year.

RESULTS

A total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice.

CONCLUSIONS AND RELEVANCE

Emergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01358110.

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

CONTEXT

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

OBJECTIVES

To assess PC competency education in EM residency programs.

METHODS

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

RESULTS

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

CONCLUSION

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

Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study

INTRODUCTION

Provision of end-of-life (EOL) care in the emergency department has improved globally in recent years and has a different scope of interventions than traditional emergency medicine. In 2010, a regional hospital established the first ED EOL service in Hong Kong.

METHODS

The aim of this study was to understand emergency nurses' perceptions regarding the provision of EOL care in the emergency department. A qualitative approach was used with purposive sampling of 16 nurses who had experience in providing EOL care. Semi-structured, face-to-face interviews were conducted from May to October, 2014. All the interviews were transcribed verbatim for content analysis.

RESULTS

Four themes were identified: (1) doing good for the dying patients, (2) facilitating family engagement and involvement, (3) enhancing personal growth and professionalism, and (4) expressing ambiguity toward resource deployment.

DISCUSSION

Provision of EOL care in the emergency department can enhance patients' last moment of life, facilitate the grief and bereavement process of families, and enhance the professional development of staff in emergency department. It is substantiated that EOL service in the emergency department enriches EOL care in the health care system. Findings from this study integrated the perspectives on ED EOL services from emergency nurses. The integration of EOL service in other emergency departments locally and worldwide is encouraged.

The Prevalence of Inpatients at 33 U.S. Hospitals Appropriate for and Receiving Referral to Palliative Care

BACKGROUND

The extent of unmet need for palliative care in U.S. hospitals remains largely unknown. We conducted a multisite cross-sectional, retrospective point prevalence analysis to determine the size and characteristics of the population of inpatients at 33 U.S. hospitals who were appropriate for palliative care referral, as well as the percentage of these patients who were referred for and/or received palliative care services. We also conducted a qualitative assessment of barriers and facilitators to referral, focusing on organizational characteristics that might influence palliative care referral practices.

METHODS

Patients appropriate for palliative care referral were defined as adult (≥18 years) patients with any diagnosis of a poor-prognosis cancer, New York Heart Association class IV congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease who had inpatient status in 1 of 33 hospitals on May 13, 2014. Qualitative assessment involved interviews of palliative care team members and nonpalliative care frontline providers.

RESULTS

Nearly 19% of inpatients on the point prevalence day were deemed appropriate for palliative care referral. Of these, approximately 39% received a palliative care referral or services. Delivery of palliative care services to these patients varied widely among participating hospitals, ranging from approximately 12% to more than 90%. Factors influencing differences in referral practices included nonstandardized perceptions of referral criteria and variation in palliative care service structures.

CONCLUSION

This study provides useful information to guide providers, administrators, researchers, and policy experts in planning for optimal provision of palliative care services to those in need.

Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review

CONTEXT

Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects.

OBJECTIVES

To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED.

METHODS

Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes.

RESULTS

Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral.

CONCLUSION

We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.

Palliative Care in the Emergency Department

Patients seek care in the emergency department (ED) for immediate relief of pain or other symptoms. Emergency physicians are trained to provide care that focuses on disease-directed treatment of acute illnesses; the ED is not considered an entry point for palliative care. Despite this, many patients with chronic or end-stage diseases seek treatment in the ED each year. Improving quality of life (QOL) is an overarching principle of palliative care. The ED is poised to improve patients' QOL by providing palliative interventions to manage pain and exacerbations of chronic illnesses or care near the end of life.

Managing the advanced cancer patient in the Australian emergency department environment: findings from a national survey of emergency department clinicians

Background

Delivery of care to people with advanced cancer in the emergency department (ED) is complicated by competing service demands, workloads and physical design constraints. We explored emergency clinicians’ attitudes to the ED environment when caring for patients who present with advanced cancer, and how these attitudes are affected by access to palliative care services, palliative care education, staff type, ED experience and patient demographic, hospital type and region.

Methods

We electronically surveyed clinicians from the College of Emergency Nursing Australasia, Australian College of Emergency Nursing and Australasian College for Emergency Medicine working in an Australian ED.

Results

Respondents were 444 doctors and 237 nurses. They reported overcrowding, noise, lack of time and privacy as barriers to care. Most (93.3%) agreed/strongly agreed that the dying patient should be allocated private space in ED. 73.6% (451) felt unable to provide a desired level of care to advanced cancer patients in ED. Clinician attitudes were affected by staff type, experience, ED demographic and hospital type, but not education in palliative care.

Conclusions

ED environments place pressure on clinicians delivering care to people with advanced cancer. Integrating palliative care services in ED and redesigning EDs to better match its multifaceted functions should be considered.

Admissions of critically ill patients to the ED intensive care unit

INTRODUCTION

Many emergency departments (EDs) have established units capable of providing critical care because of increasing need for critical care, called as ED intensive care unit (EDICU). However, prolonged critical care leads to crowding, resulting in poor quality of care and high mortality rates. We aimed to determine which type of critically ill patients play a main role for crowding in the EDICU, and how to manage these patients.

METHOD

Patients aged older than 18 years who presented to the ED and presented for consultation to the ICU were eligible for inclusion in this study. Patients were classified into 4 priority groups by the Society of Critical Care Medicine.

RESULT

Four hundred medical patients were enrolled in the study. Sixty-one patients were not admitted to hospital (15.2% of all patients) and were treated in the EDICU. These patients were older (mean age, 66.6 years) and had a higher percentage belonging to the priority 3 group (82.0%-unstable with reduced likelihood of recovery due to chronic illness) in comparison with other ICUs patients (mean age, 60.4 years and 11.9%, respectively) (P < .05). In priority 3 patients, the length of stay was median 120 hours, and also, length of invasive mechanical ventilations duration was median 19 hours in the EDICU.

CONCLUSIONS

Emergency department intensive care unit occupancy appears driven by categorized as "reduced benefit" patients, and these units tend to become alternative dumping grounds for palliative care services. Hospitals and health care administrators should take special care to develop policies for improving the management of these patients.

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.

End of life/palliative care/ethics

Palliative and end-of-life care, once the purview of oncologists and intensivists, has also become the responsibility of the emergency physician. As our population ages and medical technology enables increased longevity, it is essential that all medical professionals know how to help patients negotiate the balance between quantity and quality of life. Emergency physicians have the opportunity to educate patients and their loved ones on how to best accomplish their goals of care while also enhancing quality of life through treatment of symptoms. The emergency physician must be aware of the ethical and medico-legal parameters that govern decision making.

Understanding emergency department staff needs and perceptions in the provision of palliative care

OBJECTIVE

The primary aim of the present study was to investigate Australian ED staff perspectives and needs regarding palliative care provision. Secondary aims were to assess staff views about death and dying, and their awareness of common causes of death in Australia, particularly those where a palliative care approach is appropriate.

METHODS

All medical and nursing staff working in a private ED in Perth, Western Australia, were asked to complete a combined quantitative and qualitative survey. The survey tool uses a combination of Likert-type scales and open-ended questions. Descriptive statistics and intergroup comparisons were made for all quantifiable variables, whereas formal content analysis was used for text responses.

RESULTS

Surveys were returned by 22 doctors and 44 nurses, with most reporting only working knowledge of palliative care but clinical proficiency in symptom control. Confidence in palliative care provision was lower among nursing than medical staff but educational needs were similar. Cancer diagnoses were consistently overestimated, and dementia and COPD underestimated, as the most common causes of death. Only six of 63 (9.5%) of respondents identified the correct top five causes of death.

CONCLUSIONS

Our study suggests that although ED staff expressed confidence regarding symptom management in palliative care, they lacked understanding of the patients in whom a palliative approach could be applied and sought further education in areas, such as end-of-life communication and ethical issues. ED specific training and clinical interventions in palliative care provision would seem to be needed and justified.

Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration

BACKGROUND

Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles.

CASE REPORT

We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care.

DISCUSSION

We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort.

CONCLUSION

The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.

When a patient declines curative care: management of a ruptured aortic aneurysm

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case. We present the case of a 72-year-old patient who presented to the ED with a ruptured abdominal aortic aneurysm, but refused surgery. We discuss the transition of the patient from a curative to a comfort care approach with appropriate direct referral to hospice from the ED. Using principles of autonomy, decision-making capacity, informed consent, prognostication, and goals-of-care, ED clinicians are best able to align their approach with patients' goals and values.

Research priorities in geriatric palliative care: nonpain symptoms

Research addressing the burden, assessment, and management of nonpain symptoms associated with advanced illness in older adults is limited. While nonpain symptoms such as fatigue, sleep, dyspnea, anxiety, depression, cognitive impairment, nausea, and anorexia-cachexia are commonly noted by patients and clinicians, research quantifying their effects on quality of life, function, and other outcomes are lacking and there is scant evidence regarding management. Most available studies have focused on relatively narrow conditions (e.g., chemotherapy-induced nausea) and there are almost no data relevant to patients with multiple morbidities or multiple concurrent symptoms. Assessment and treatment of nonpain symptoms in older adults with serious illness and multiple comorbidities is compromised by the lack of data relevant to their care. Recommended research priorities address the documented high prevalence of distressing symptoms in older adults with serious illness, the unique needs of this population due to coexistence of multiple chronic conditions along with physiologic changes related to aging, the lack of evidence for effective pharmacologic and nonpharmacologic interventions, and the need for validated measures that are relevant across multiple care settings.

Dysphagia as a predictor of outcome and transition to palliative care among middle cerebral artery ischemic stroke patients

BACKGROUND

Middle Cerebral Artery (MCA) territory strokes can be disabling and may leave patients unable to swallow safely. Decisions regarding artificial nutrition and goals of care often arise in patients with severe strokes leading to dysphagia. This study determined some predictors of early transition to palliative level of care among patients with acute ischemic MCA stroke with dysphagia.

METHODS

This is a retrospective cohort study. Demographic and clinical data of patients presenting to Hartford Hospital with an acute ischemic stroke between January 2005-December 2010 were gathered utilizing the Stroke Center at Hartford Hospital Database. The 236 patients included were divided into "early transition" and "not transitioned" to palliative care cohorts. Primary outcome was transition to palliative care. Factors that were significantly associated with an early transition to palliative level of care in univariate analysis were then entered into a multivariate logistic regression analysis to identify potential independent predictors of early transition to palliative level of care. The significance level was set at p < 0.05.

RESULTS

79 patients (34%) were transitioned to palliative level of care after failing the first swallow evaluation within a median of 3 days. Factors predictive of an early transition to palliative level of care after multivariate logistic regression analysis included advancing age (p < 0.001; OR: 1.10; 95% CI :1.056-1.155) , left MCA infarct (p = 0.039; OR: 0.417; 95% CI:0.182-0.956), a high NIHSS score on admission (p = 0.017; OR: 3.038; 95% CI: 1.22-7.555), administration of intra-arterial tPA (p < 0.001; OR: 7.106; 955 CI 2.541-19.873) and the inability to be assessed on the 1(st) swallow evaluation (p < 0.001; OR 0.053; 95% CI 0.022-0.131).

CONCLUSIONS

The severity of dysphagia influences early transition to palliative level of care in acute stroke patients. Independent predictors of an early transition to palliative level of care among patients with an acute MCA territory stroke and dysphagia included advancing age, a left MCA infarct, a high NIHSS score on admission, administration of intra-arterial tPA and the inability to be assessed on the 1(st) swallow evaluation. This information may guide discussions with families of patients with MCA territory strokes regarding artificial nutrition and goals of care.

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

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

Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals

BACKGROUND

The requirement to meet the palliative needs of acute hospital populations has grown in recent years. With increasing numbers of frail older people needing hospital care as a result of both malignant and non-malignant conditions, emphasis is being placed upon understanding the physical, psychological and social burdens experienced by patients. This study explores the extent of burden in two large UK hospitals, focusing upon those patients who meet palliative care criteria. Furthermore, the paper explores the use of palliative services and identifies the most significant clinical diagnostic and demographic factors which determine physical and psychological burden.

METHODS

Two hospital surveys were undertaken to identify burden using the Sheffield Profile for Assessment and Referral to Care (SPARC). The Gold Standards Framework (GSF) is used to identify those patients meeting palliative care criteria. Participants were identified as being in-patients during a two-week data collection phase for each site. Data was gathered using face-to-face interviews or self-completion by patients or a proxy. Descriptive analyses highlight prevalence and use of palliative care provision. Binary logistic regression assesses clinical diagnostic predictor variables of physical and psychological burden.

RESULTS

The sample consisted of 514 patients and elevated physical, psychological and social burden is identified amongst those meeting palliative care criteria (n = 185). Tiredness (34.6%), pain (31.1%), weakness (28.8%) and psychological discomfort (low mood 19.9%; anxiety 16.1%) are noted as being prevalent. A small number of these participants accessed Specialist Palliative Care (8.2%). Dementia was identified as a predictor of physical (OR 3.94; p < .05) and psychological burden (OR 2.88; p < .05), being female was a predictor of psychological burden (OR 2.00; p < .05).

CONCLUSION

The paper highlights elevated levels of burden experienced by patients with palliative care requirements. Moreover, the paper also indicates that a large proportion of such patients are not in receipt of palliative approaches to their care. Furthermore, the paper identifies that those with non-malignant illnesses, especially dementia, may experience high levels of physical and psychological burden.

Palliative care provision in the emergency department: barriers reported by emergency physicians

BACKGROUND

There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated.

OBJECTIVE

To elicit the ED physicians' perceived barriers to provision of PC in the ED.

METHODS

ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers).

RESULTS

Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation.

CONCLUSION

We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.

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.