1
|
de Oliveira R, Lobato CB, Maia-Moço L, Santos M, Neves S, Matos MF, Cardoso R, Cruz C, Silva CA, Dias J, Maçães A, Almeida S, Gonçalves AP, Gomes B, Freire E. Palliative medicine in the emergency department: symptom control and aggressive care. BMJ Support Palliat Care 2023; 13:e476-e483. [PMID: 34470770 DOI: 10.1136/bmjspcare-2021-003332] [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] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Identifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care. METHODS We conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson's Index. RESULTS 384 adults died at the ED (median age 82 (IQR 72-89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2-4) vs 3 (2-5)), p=0.082. CONCLUSIONS Nearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.
Collapse
Affiliation(s)
- Raquel de Oliveira
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Carolina B Lobato
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Endocrine and Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB) & Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal
- Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| | - Leonardo Maia-Moço
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Cancer Biology and Epigenetics Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Mariana Santos
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Sara Neves
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | | | - Rosa Cardoso
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Carla Cruz
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Cátia Araújo Silva
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Joana Dias
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - André Maçães
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Soraia Almeida
- Emergency Department, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
- Infectious Diseases Department, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| | | | - Barbara Gomes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Cicely Saunders Institute of Palliative Care and Rehabilitation, Policy and Rehabilitation, King's College London, London, UK
| | - Elga Freire
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Palliative Care Unit, Department of Internal Medicine, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| |
Collapse
|
2
|
Lu Y, Ren C, Wu C. In-Hospital Mortality Prediction Model for Critically Ill Older Adult Patients Transferred from the Emergency Department to the Intensive Care Unit. Risk Manag Healthc Policy 2023; 16:2555-2563. [PMID: 38024492 PMCID: PMC10676667 DOI: 10.2147/rmhp.s442138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Studies on the prognosis of critically ill older adult patients admitted to the emergency department (ED) but requiring immediate admission to the intensive care unit (ICU) remain limited. This study aimed to develop an in-hospital mortality prediction model for critically ill older adult patients transferred from the ED to the ICU. Patients and Methods The training cohort was taken from the Medical Information Mart for Intensive Care IV (version 2.2) database, and the external validation cohort was taken from the Affiliated Dongyang Hospital of Wenzhou Medical University. In the training cohort, class balance was addressed using Random Over Sampling Examples (ROSE). Univariate and multivariate Cox regression analyses were performed to identify independent risk factors. These were then integrated into the predictive nomogram. In the validation cohort, the predictive performance of the nomogram was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, calibration curve, clinical utility decision curve analysis (DCA), and clinical impact curve (CIC). Results In the ROSE-balanced training cohort, univariate and multivariate Cox regression analysis identified that age, sex, Glasgow coma scale score, malignant cancer, sepsis, use of mechanical ventilation, use of vasoactive agents, white blood cells, potassium, and creatinine were independent predictors of in-hospital mortality in critically ill older adult patients, and were included in the nomogram. The nomogram showed good predictive performance in the ROSE-balanced training cohort (AUC [95% confidence interval]: 0.792 [0.783-0.801]) and validation cohort (AUC [95% confidence interval]: 0.780 [0.727-0.834]). The calibration curves were well-fitted. DCA and CIC demonstrated that the nomogram has good clinical application value. Conclusion This study developed a predictive model for early prediction of in-hospital mortality in critically ill older adult patients transferred from the ED to the ICU, which was validated by external data and has good predictive performance.
Collapse
Affiliation(s)
- Yan Lu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaoxiang Ren
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaolong Wu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| |
Collapse
|
3
|
Snijders RAH, Brom L, Simons SO, Langenberg SMCH, van der Linden YM, Raijmakers NJH. Referrals to Palliative Care Services for Hospitalised COVID-19 Patients: A Systematic Literature Review. Am J Hosp Palliat Care 2023:10499091231215797. [PMID: 37975523 DOI: 10.1177/10499091231215797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The increase in the incidence of the coronavirus disease 2019 (COVID-19) led to more hospital admissions and deaths, and coincided with an increased need for palliative care. The new circumstances required palliative care services to be flexible and to develop response strategies. AIM To synthesise studies including COVID-19 patients to gain insight into how many patients were referred to hospital-based palliative care services, the characteristics and palliative care needs of these patients and the reasons for referral. DESIGN A systematic literature search was conducted in January 2022 using the PubMed, Embase, CINAHL, and PsycInfo databases. RESULTS Twenty-seven studies were identified. The results show that in 16% of all COVID-19 inpatients and 55% of all deceased COVID-19 inpatients were referred to a palliative care service. The median time from hospital admission to referral was 4 days and from referral to death was 2 days. COVID-19 inpatients were frequently referred for end-of-life care management (52%), had ≥1 comorbidities (84%), and suffered from shortness of breath/dyspnea (45%). CONCLUSIONS The care provided was generally acute, with a high proportion of end-of-life care referrals and a short time period from hospital admission to referral and from referral to death. This highlights the importance of early integration of palliative care into emergency department (ED) care of critically ill patients.
Collapse
Affiliation(s)
- Rolf A H Snijders
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Linda Brom
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Sami O Simons
- Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Simone M C H Langenberg
- Department of Anesthesiology, Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Yvette M van der Linden
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Natasja J H Raijmakers
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| |
Collapse
|
4
|
Kirkland SW, Yang EH, Garrido Clua M, Kruhlak M, Campbell S, Villa-Roel C, Rowe BH. Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review. Acad Emerg Med 2022; 29:1229-1246. [PMID: 35344239 DOI: 10.1111/acem.14492] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED). METHODS A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs). RESULTS A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%. CONCLUSIONS This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.
Collapse
Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Orthopaedic Surgery, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Maureen Kruhlak
- School of Veterinary Medicine, St. George's University, West Indies, Grenada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
5
|
Kirkland SW, Garrido Clua M, Kruhlak M, Villa-Roel C, Couperthwaite S, Yang EH, Elwi A, O’Neill B, Duggan S, Brisebois A, Rowe BH. Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs. PLoS One 2021; 16:e0257501. [PMID: 34570790 PMCID: PMC8476017 DOI: 10.1371/journal.pone.0257501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/02/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared. METHODS Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs. CONCLUSIONS Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.
Collapse
Affiliation(s)
- Scott W. Kirkland
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | | | - Maureen Kruhlak
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | | | - Esther H. Yang
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Adam Elwi
- Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Shelley Duggan
- Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| |
Collapse
|
6
|
Emergency Department Referral for Hospice and Palliative Care Differs among Patients with Different End-of-Life Trajectories: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126286. [PMID: 34200689 PMCID: PMC8296068 DOI: 10.3390/ijerph18126286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022]
Abstract
Emergency units have been gradually recognized as important settings for palliative care initiation, but require precise palliative care assessments. Patients with different illness trajectories are found to differ in palliative care referrals outside emergency unit settings. Understanding how illness trajectories associate with patient traits in the emergency department may aid assessment of palliative care needs. This study aims to investigate the timing and acceptance of palliative referral in the emergency department among patients with different end-of-life trajectories. Participants were classified into three end-of-life trajectories (terminal, frailty, organ failure). Timing of referral was determined by the interval between the date of referral and the date of death, and acceptance of palliative care was recorded among participants eligible for palliative care. Terminal patients had the highest acceptance of palliative care (61.4%), followed by those with organ failure (53.4%) and patients with frailty (50.1%) (p = 0.003). Terminal patients were more susceptible to late and very late referrals (47.4% and 27.1%, respectively) than those with frailty (34.0%, 21.2%) and with organ failure (30.1%, 18.8%) (p < 0.001, p = 0.022). In summary, patients with different end-of-life trajectories display different palliative care referral and acceptance patterns. Acknowledgement of these characteristics may improve palliative care practice in the emergency department.
Collapse
|
7
|
Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031028. [PMID: 33503811 PMCID: PMC7908360 DOI: 10.3390/ijerph18031028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022]
Abstract
Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.
Collapse
|