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Mullins MA, Ruterbusch J, Cote ML, Uppal S, Wallner LP. Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities. Int J Gynecol Cancer 2023; 33:1099-1105. [PMID: 37208020 PMCID: PMC10577799 DOI: 10.1136/ijgc-2023-004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer. METHODS This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression. RESULTS In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death. CONCLUSION Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Julie Ruterbusch
- Karmanos Cancer Insitute, Wayne State University, Detroit, Michigan, USA
| | - Michele L Cote
- Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana, USA
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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2
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Aaronson EL, Kennedy M, Gillis-Crouch G, Zheng H, Jacobsen J, Ouchi K, Jackson V, Ritchie CS, Gioiella ME, Greenwald JL. Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values. J Palliat Med 2023; 26:517-526. [PMID: 36576866 PMCID: PMC10325815 DOI: 10.1089/jpm.2022.0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 12/29/2022] Open
Abstract
Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Gillis-Crouch
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Zheng
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Seel Ritchie
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marie Elena Gioiella
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey L. Greenwald
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Wright R, Lowton K, Hansen BR, Grocott P. Older adult and family caregiver preferences for emergency department based-palliative care: An experience-based co-design study. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2020.100016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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4
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Aaronson EL, Daubman BR, Petrillo L, Bowman J, Ouchi K, Gips A, Traeger L, Jackson V, Grudzen C, Ritchie CS. Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic. J Pain Symptom Manage 2021; 62:117-124. [PMID: 33161031 PMCID: PMC7645272 DOI: 10.1016/j.jpainsymman.2020.10.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. OBJECTIVES To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. METHODS For this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations. RESULTS Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories. CONCLUSION Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexa Gips
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Palliative Care Service, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lara Traeger
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Corita Grudzen
- Department of Emergency Medicine, NYU Langone Health/Bellevue Hospital Center, NYU Grossman School of Medicine, New York, USA
| | - Christine Seel Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
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5
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Chang JCY, Yang C, Lai LL, Huang HH, Fan JS, Lin MH, Hsu TF, Yen DHT. Differences in end-of-life care and outcomes in palliative consultation-eligible patients with and without do-not-resuscitate orders: A propensity score-matched study. J Chin Med Assoc 2021; 84:633-639. [PMID: 33871389 DOI: 10.1097/jcma.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. METHODS This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. RESULTS A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). CONCLUSION The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.
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Affiliation(s)
- Julia Chia-Yu Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Ling Lai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Teh-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Emergency Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC
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6
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Stoltenberg M, Jacobsen J, Wilson E, Daubman BR, Ritchie CS, Petrillo L, Jackson V, Loving Aaronson E. Emergency Department-Based Palliative Care during COVID. J Palliat Med 2020; 23:1151-1152. [PMID: 32579868 DOI: 10.1089/jpm.2020.0285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mark Stoltenberg
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erica Wilson
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine Seel Ritchie
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura Petrillo
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily Loving Aaronson
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA
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7
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Abstract
Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.
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Affiliation(s)
- Rita C. Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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8
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Death and Dying in the Emergency Department. Adv Emerg Nurs J 2020; 42:81-89. [PMID: 32358420 DOI: 10.1097/tme.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. For each column, a topic and a particular research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. Our current column discusses factors associated with the quality of the death and dying experience in the emergency department (ED) from the perspective of health care providers with implications for APRN practice and strategies using the following study: . "Exploring the quality of the dying and death experience in the emergency department: An integrative literature review," International Journal of Nursing Studies, 85, 106-117. Our case involves a man with metastatic colon cancer where his oncology nurse practitioner recommends no further treatment and tells him he has approximately 6 months to live.
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9
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Yang C, Yang TT, Tsou YJ, Lin MH, Fan JS, Huang HH, Tsai MC, Yen DHT. Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit. J Chin Med Assoc 2020; 83:500-506. [PMID: 32168079 DOI: 10.1097/jcma.0000000000000297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU). METHODS We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization. RESULTS A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05). CONCLUSION Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.
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Affiliation(s)
- Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tsu-Te Yang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yu-Ju Tsou
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Hui Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ming-Che Tsai
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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10
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George N, Bowman J, Aaronson E, Ouchi K. Past, present, and future of palliative care in emergency medicine in the USA. Acute Med Surg 2020; 7:e497. [PMID: 32395248 PMCID: PMC7204801 DOI: 10.1002/ams2.497] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/12/2020] [Indexed: 01/15/2023] Open
Abstract
The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill‐equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM–palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high‐quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.
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Affiliation(s)
- Naomi George
- University of New Mexico Albuquerque New Mexico.,Division of Critical Care Brigham and Women's Hospital Boston Massachusetts
| | - Jason Bowman
- Division of Critical Care Brigham and Women's Hospital Boston Massachusetts.,Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts
| | - Emily Aaronson
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts
| | - Kei Ouchi
- Division of Critical Care Brigham and Women's Hospital Boston Massachusetts.,Department of Palliative Care and Psychosocial Oncology Dana Farber Cancer Institute Boston Massachusetts
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11
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Wilson JG, English DP, Owyang CG, Chimelski EA, Grudzen CR, Wong HN, Aslakson RA. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage 2020; 59:372-383.e1. [PMID: 31586580 DOI: 10.1016/j.jpainsymman.2019.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT There is growing interest in providing palliative care (PC) in the emergency department (ED), but relatively little is known about the efficacy of ED-based PC interventions. A 2016 systematic review on this topic found no evidence that ED-based PC interventions affect patient outcomes or health care utilization, but new research has emerged since the publication of that review. OBJECTIVES This systematic review provides a concise summary of current literature addressing the impact of ED-based PC interventions on patient-reported or family reported outcomes, health care utilization, and survival. METHODS We searched PubMed, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature from inception until September 1, 2018 and reviewed references. Eligible articles evaluated the effects of PC interventions in the ED on patient-reported or family reported outcomes, health care utilization, or survival. RESULTS We screened 3091 abstracts and 98 full-text articles with 13 articles selected for final inclusion. Two articles reported the results of a single randomized controlled trial, whereas the remaining 11 studies were descriptive or quasi-experimental cohort studies. More than half of the included articles were published after the previous systematic review on this topic. Populations studied included older adults, patients with advanced malignancy, and ED patients screening positive for unmet PC needs. Most interventions involved referral to hospice or PC or PC provided directly in the ED. Compared with usual care, ED-PC interventions improved quality of life, although this improvement was not observed when comparing ED-PC to inpatient PC. ED-PC interventions expedited PC consultation; most studies reported a concomitant reduction in hospital length of stay and increase in hospice utilization, but some data were conflicting. Short-term mortality rates were high across all studies, but ED-PC interventions did not decrease survival time compared with usual care. CONCLUSION Existing data support that PC in the ED is feasible, may improve quality of life, and does not appear to affect survival.
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Affiliation(s)
- Jennifer G Wilson
- Department of Emergency Medicine, Stanford University, Stanford, California, USA.
| | - Diana P English
- Division of Hospice and Palliative Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Clark G Owyang
- Division of Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Erica A Chimelski
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA; Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Divisions of Critical Care and Hospice and Palliative Medicine, Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA
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12
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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13
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Chor WPD, Wong SYP, Ikbal MFBM, Kuan WS, Chua MT, Pal RY. Initiating End-of-Life Care at the Emergency Department: An Observational Study. Am J Hosp Palliat Care 2019; 36:941-946. [PMID: 30862168 DOI: 10.1177/1049909119836931] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Terminally ill patients at their end-of-life (EOL) phase attending the emergency department (ED) may have complex and specialized care needs frequently overlooked by ED physicians. To tailor to the needs of this unique group, the ED in a tertiary hospital implemented an EOL pathway since 2014. The objective of our study is to describe the epidemiological characteristics, symptom burden and management of patients using a protocolized management care bundle. METHODS We conducted an observational study on the database of EOL patients over a 28-month period. Patients aged 21 years and above, who attended the ED and were managed according to these guidelines, were included. Clinical data were extracted from the hospital's electronic medical records system. RESULTS Two hundred five patients were managed under the EOL pathway, with a slight male predominance (106/205, 51.7%) and a median age of 78 (interquartile range 69-87) years. The majority were chronically frail (42.0%) or diagnosed with cancer or other terminal illnesses (32.7%). The 3 most commonly experienced symptoms were drowsiness (66.3%), dyspnea (61.5%), and fever (29.7%). Through the protocolized management care bundle, 74.1% of patients with dyspnea and/or pain received opiates while 59.5% with copious secretions received hyoscine butylbromide for symptomatic relief. CONCLUSION The institution of a protocolized care bundle is feasible and provides ED physicians with a guide in managing EOL patients. Though still suboptimal, considerable advances in EOL care at the ED have been achieved and may be further improved through continual education and enhancements in the care bundle.
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Affiliation(s)
- Wei Ping Daniel Chor
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | | | | | - Win Sen Kuan
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,3 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mui Teng Chua
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,3 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rakhee Yash Pal
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
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Missed Opportunities: Integrating Palliative Care into the Emergency Department for Older Adults Presenting as Level I Triage Priority from Long-Term Care Facilities. J Emerg Med 2018; 56:145-152. [PMID: 30527561 DOI: 10.1016/j.jemermed.2018.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/29/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care. OBJECTIVE Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement. METHODS We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed. RESULTS Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%). CONCLUSIONS Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED.
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15
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McCallum KJ, Jackson D, Walthall H, Aveyard H. Exploring the quality of the dying and death experience in the Emergency Department: An integrative literature review. Int J Nurs Stud 2018; 85:106-117. [DOI: 10.1016/j.ijnurstu.2018.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 10/16/2022]
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16
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Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents. CAN J EMERG MED 2018; 21:211-218. [DOI: 10.1017/cem.2018.371] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractObjectiveFew studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.MethodsA team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.ResultsSurveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).ConclusionsImportant barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.
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17
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Kim K, Chakravarthy B, Anderson C, Liao S. To Intubate or Not to Intubate: Emergency Medicine Physicians' Perspective on Intubating Critically Ill, Terminal Cancer Patients. J Pain Symptom Manage 2017; 54:654-660.e1. [PMID: 28754440 DOI: 10.1016/j.jpainsymman.2017.07.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/15/2017] [Accepted: 07/18/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT Emergency physicians (EPs) often need to make a decision whether or not to intubate a terminal cancer patient. OBJECTIVE The objective of this study was to explore EPs' attitudes about intubating critically ill, terminal cancer patients. METHODS Fifty EPs at three emergency departments (one university based, one community, and one Health Maintenance Organization) in Southern California participated in an anonymous survey that presented a hypothetical case of an end-stage lung cancer patient in pending respiratory failure. Fourteen questions along a five-point Likert scale asked EPs about prognosis and factors that influence their decision to intubate or not. RESULTS A convenience sampling of 50 EPs yielded a 100% survey response rate. Ninety-four percent believed intubation would not provide an overall survival benefit. If the family insisted, 26% would intubate the patient even with a do-not-intubate (DNI) status. Ninety-four percent would postpone intubation if palliative consultation were available in the ED. Sixty-eight percent believed that a discussion about goals of care was more time consuming than intubation. Only 16% believed they had sufficient training in palliative care. Although 29% who felt they had inadequate palliative care training would intubate the patient with a DNI, only 13% of EPs with self-perceived adequate palliative care training would intubate that patient. CONCLUSION EPs vary in their attitudes about intubating dying cancer patients when families demanded it, even when they believed it was nonbeneficial and against the patient's wishes. Palliative care education has the potential to influence that decision making. Intubation could be mitigated by the availability of palliative consultation in the ED.
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Affiliation(s)
- Kenneth Kim
- Department of Palliative Medicine, University of California, Irvine, California, USA.
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Craig Anderson
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Solomon Liao
- Department of Palliative Medicine, University of California, Irvine, California, USA
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18
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Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral. J Emerg Med 2017; 54:191-197. [PMID: 28988735 DOI: 10.1016/j.jemermed.2017.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/22/2017] [Accepted: 08/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease. OBJECTIVES To investigate the effectiveness of our AI Management program in the ED on key outcomes. METHODS We conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate. RESULTS Our sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001). CONCLUSIONS The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.
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Cornillon P, Loiseau S, Aublet-Cuvelier B, Guastella V. Reasons for transferral to emergency departments of terminally ill patients - a French descriptive and retrospective study. BMC Palliat Care 2016; 15:87. [PMID: 27769258 PMCID: PMC5073929 DOI: 10.1186/s12904-016-0155-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 09/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients under palliative care and in hospital-at-home services are frequently transferred to emergency departments. We set out to identify the reasons for these presentations to determine the proportion that might be avoidable. METHODS We conducted a retrospective study by assessment of patient files. We studied admissions to four emergency departments in an area of France (Puy-de-Dôme) between September 2011 and August 2013. Reasons for transfer and diagnostic conclusion by emergency doctors were noted. We collected date of admission, time spent, investigations and treatments performed and patients' outcomes after the medical conclusions. We also determined whether patients called the hospital-at-home service before going to the emergency department. From these data we discerned potentially avoidable and unavoidable consultations. RESULTS We identified 52 transfers of patients from home to emergency departments. The most frequent reasons were: generalized weakness (11 cases), social isolation (8 cases) and end of life (7 cases). For 58 % of presentations, the investigations and treatments performed did not require presentation to an emergency department; 34 % of patients returned home after the visit, 41 % remained for simple observation and 20 % remained to receive special care. Two patients died in the emergency department. In 86 % of cases, presentations occurred when primary care was less readily available, and patients called home care services in only 42 % of cases before going to emergency departments. CONCLUSIONS Half of the transfers to emergency departments were potentially avoidable for terminally ill patients in home care. To reduce this proportion we need to promote access to primary care, educate patients in hospital-at-home service and train care-givers and doctors in palliative medicine.
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Affiliation(s)
- Pierre Cornillon
- Department of Palliative Care, Centre hospitalier Universitaire, Hopital Nord, 63000 Clermont-Ferrand, France
| | | | - Bruno Aublet-Cuvelier
- Department of Palliative Care, Centre hospitalier Universitaire, Hopital Nord, 63000 Clermont-Ferrand, France
| | - Virginie Guastella
- Department of Palliative Care, Centre hospitalier Universitaire, Hopital Nord, 63000 Clermont-Ferrand, France
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20
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Lamba S, DeSandre PL, Quest TE. Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine. J Emerg Med 2016; 51:658-667. [PMID: 27613448 DOI: 10.1016/j.jemermed.2016.06.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/28/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. DISCUSSION We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. CONCLUSION The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Paul L DeSandre
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia
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21
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A Pilot Trial to Increase Hospice Enrollment in an Inner City, Academic Emergency Department. J Emerg Med 2016; 51:106-13. [DOI: 10.1016/j.jemermed.2016.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 02/04/2016] [Accepted: 03/26/2016] [Indexed: 11/18/2022]
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22
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da Silva Soares D, Nunes CM, Gomes B. Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review. J Palliat Med 2016; 19:601-9. [PMID: 27115914 PMCID: PMC4904160 DOI: 10.1089/jpm.2015.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evidence on best practice is scarce. OBJECTIVES To examine the effectiveness of ED-based PC interventions on hospital admissions (primary outcome), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults with advanced disease. METHODS We searched five databases until August 2014, checked reference lists/conference abstracts, and contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting outcomes of ED-based PC. RESULTS Five studies with 4374 participants were included: three case series and two cohort studies. Interventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital admissions: in one study there was no statistically significant difference in 90-day readmission rates between patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other outcomes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21-3.41); another study showed increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value). CONCLUSIONS There is yet no evidence that ED-based PC affects patient outcomes except for indication from one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these findings alongside other potential benefits and survival effects.
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Affiliation(s)
| | - Cristina Moura Nunes
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Bragança, Portugal
| | - Barbara Gomes
- Department of Palliative Care, Policy, and Rehabilitation, Cicely Saunders Institute, King's College, London, United Kingdom
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23
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Elsayem AF, Elzubeir HE, Brock PA, Todd KH. Integrating palliative care in oncologic emergency departments: Challenges and opportunities. World J Clin Oncol 2016; 7:227-33. [PMID: 27081645 PMCID: PMC4826968 DOI: 10.5306/wjco.v7.i2.227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.
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24
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Obermeyer Z, Clarke AC, Makar M, Schuur JD, Cutler DM. Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis. J Am Geriatr Soc 2016; 64:323-9. [PMID: 26805592 DOI: 10.1111/jgs.13948] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not. DESIGN Matched case-control study. SETTING Nationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011. PARTICIPANTS Beneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex. MEASUREMENTS Comparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls. RESULTS Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3-10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45-1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4-36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6-14.2%) of stays longer than 1 month. CONCLUSION Most Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.
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Affiliation(s)
- Ziad Obermeyer
- Department of Emergency Medicine, School of Medicine, Harvard University, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts
| | - Alissa C Clarke
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maggie Makar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, School of Medicine, Harvard University, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts.,National Bureau of Economic Research, Cambridge, Massachusetts
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25
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Affiliation(s)
- Eric M LeFebvre
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC.
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Delgado-Guay MO, Rodriguez-Nunez A, Shin SH, Chisholm G, Williams J, Frisbee-Hume S, Bruera E. Characteristics and outcomes of patients with advanced cancer evaluated by a palliative care team at an emergency center. A retrospective study. Support Care Cancer 2015; 24:2287-2295. [DOI: 10.1007/s00520-015-3034-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/15/2015] [Indexed: 11/30/2022]
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Rogers IR, Lukin B. Applying palliative care principles and practice to emergency medicine. Emerg Med Australas 2015; 27:612-615. [DOI: 10.1111/1742-6723.12494] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ian R Rogers
- Department of Emergency Medicine; St John of God Murdoch Hospital; Perth Western Australia Australia
- The University of Notre Dame Australia; Fremantle Western Australia Australia
| | - Bill Lukin
- Department of Emergency Medicine; Royal Brisbane Hospital; Brisbane Queensland Australia,
- University of Queensland; Brisbane Queensland Australia
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28
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Moretti C, Quadri G, D'Ascenzo F, Bertaina M, Giusto F, Marra S, Moiraghi C, Scaglione L, Torchio M, Montrucchio G, Bo M, Porta M, Cavallo Perin P, Marinone C, Riccardini F, Iqbal J, Omedè P, Bergerone S, Veglio F, Gaita F. THE STORM (acute coronary Syndrome in paTients end Of life and Risk assesMent) study. Emerg Med J 2015; 33:10-6. [DOI: 10.1136/emermed-2014-204114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 04/01/2015] [Indexed: 12/11/2022]
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Shearer FM, Rogers IR, Monterosso L, Ross-Adjie G, Rogers JR. Understanding emergency department staff needs and perceptions in the provision of palliative care. Emerg Med Australas 2014; 26:249-55. [PMID: 24713040 DOI: 10.1111/1742-6723.12215] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Freya M Shearer
- Emergency Department, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
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Lamba S, DeSandre PL, Todd KH, Bryant EN, Chan GK, Grudzen CR, Weissman DE, Quest TE. Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration. J Emerg Med 2013; 46:264-70. [PMID: 24286714 DOI: 10.1016/j.jemermed.2013.08.087] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 07/16/2013] [Accepted: 08/16/2013] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Paul L DeSandre
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Knox H Todd
- Department of Emergency Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Eric N Bryant
- The Institute for Palliative Medicine at San Diego Hospice, San Diego, California
| | - Garrett K Chan
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California; Emergency Department Clinical Decision Unit and Palliative Care Service, Stanford Hospital & Clinics, Stanford, California
| | - Corita R Grudzen
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David E Weissman
- Medical College of Wisconsin Palliative Care Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tammie E Quest
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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