1
|
Albanesi B, Conti A, Politano G, Dimonte V, Gianino MM, Campagna S. Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019. BMC Geriatr 2024; 24:295. [PMID: 38549053 PMCID: PMC10976813 DOI: 10.1186/s12877-024-04912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/21/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits. METHODS A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits. RESULTS In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31). CONCLUSIONS Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.
Collapse
Affiliation(s)
- Beatrice Albanesi
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Alessio Conti
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy.
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Turin, Italy
| | - Valerio Dimonte
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Maria Michela Gianino
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Sara Campagna
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| |
Collapse
|
2
|
Wang YJ, Hsu CY, Yen AMF, Chen HH, Lai CC. Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department. BMC Palliat Care 2024; 23:51. [PMID: 38389106 PMCID: PMC10885365 DOI: 10.1186/s12904-024-01391-w] [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: 12/12/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired. METHODS We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year. RESULTS A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic. CONCLUSIONS The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.
Collapse
Affiliation(s)
- Yu-Jing Wang
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
- Medical Department, Daichung Hospital, Miaoli, Taiwan
- Taiwan Association of Medical Screening, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan.
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
3
|
Pires L, Rosendo I, Seiça Cardoso C. [Palliative Care Needs in Primary Health Care: Characteristics of Patients with Advanced Cancer and Dementia]. ACTA MEDICA PORT 2024; 37:90-99. [PMID: 37579749 DOI: 10.20344/amp.20049] [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: 04/15/2023] [Accepted: 05/30/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION The increase in life expectancy brought a higher prevalence of chronic diseases, with an emphasis on those who reached advanced stages and required palliative care. We aimed to characterize patients diagnosed with advanced neoplasms and/or dementia accompanied in primary health care and to test the sensitivity of two tools for identifying patients with palliative needs. METHODS We recruited three voluntary family physicians who provided data relative to 623 patients with active codification for neoplasm and/or dementia on the MIM@UF platform. We defined 'patient with palliative needs' as any patient with this codification in advanced stadium and made their clinical and sociodemographic characterization. Assuming the existence of advanced-stage disease as the gold standard, we calculated and compared the sensitivities of each of the tools under study: the surprise question, the question 'do you think this patient has palliative needs?' and an instrument that corresponded to identification by at least one of the questions. RESULTS Among the analyzed data, there were 559 (89.7%) active codifications of neoplasm and 64 (10.3%) of dementia; the prevalence of advanced neoplasm and dementia was 1.0% in the studied sample. The subgroup of patients with advanced dementia showed female sex predominance, an older age, and less access to health care. In both subgroups there was a scarcity of data related to education and income, and we observed polypharmacotherapy and multimorbidity. The sensitivity of the surprise question was 33.3% for neoplasia and 69.3% for dementia; of the new tool 50.0% for neoplasia and 92.3% for dementia; and, when used together, 55.6% for neoplasia and 92.3% for dementia. CONCLUSION Our results help characterize two subpopulations of patients in need of palliative care and advance with a possible tool for their identification, to be confirmed in a representative sample.
Collapse
Affiliation(s)
- Luís Pires
- Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
| | - Inês Rosendo
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Unidade de Saúde Familiar Coimbra Centro. Coimbra. Portugal
| | - Carlos Seiça Cardoso
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Unidade de Saúde Familiar Condeixa. Coimbra. Portugal
| |
Collapse
|
4
|
Reid E, Lukoma M, Ho D, Bagasha P, Leng M, Namukwaya L. Palliative care needs and barriers in an urban Ugandan Emergency Department: A mixed-methods survey of emergency healthcare workers and patients. Afr J Emerg Med 2023; 13:339-344. [PMID: 38162896 PMCID: PMC10757186 DOI: 10.1016/j.afjem.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024] Open
Abstract
Background Palliative Care offers patient-centered, symptom-focused relief for patients with incurable disease, and early integration of palliative care ensures quality of life and death while reducing medical impoverishment. The Emergency Department is an ideal yet understudied, under-utilized location to initiate palliative care. Objective To evaluate the palliative care needs of patients with incurable disease and perceived barriers amongst healthcare providers in the Emergency Department of Kiruddu National Referral Hospital, Kampala, Uganda. Methods A mixed methods survey of Emergency Department healthcare workers and patients was conducted. A crosse sectional survey of ninety-nine patients was conducted using the integrated Palliative Care Outcome Scale (IPOS). Eleven interviews were conducted with healthcare workers at Kiruddu Hospital, identified by purposive sampling. Descriptive and inferential statistics were used to analyze quantitative data.. Grounded theory approach was used to construct the in depth interview questions, code and analyze qualitative results and collapse these results into final themes. Results The most common diagnoses were HIV/HIV-TB (32 %), heart disease (18 %), and sickle cell disease (14 %). The prevalence of unmet palliative care needs was substantial: more that 70 % of patients reported untreated symptoms e.g., pain, fatigue, difficulty breathing. Seventy-seven percent of the population reported severe or overwhelming pain. The main barriers to provision of palliative care in the Emergency Department as identified by healthcare workers were: (1) lack of adequate training in palliative care; (2) Challenges due to patient volume and understaffing; (3) the misconception that palliative care is associated with pain management alone; (4) Financial constraints as the greatest challenge faced by patients with incurable disease. Conclusions We report a high prevalence of unmet palliative care needs among patients in this urban Ugandan Emergency Department, and important barriers reported by emergency healthcare providers. Identification of these barriers offers opportunities to overcome them including harnessing novel mHealth interventions such as clinical support apps or telehealth palliative care consultants. Integration of palliative care in this setting would improve the care of vulnerable patients, provide healthcare workers with an additional care modality while likely adding value to the health system.
Collapse
Affiliation(s)
- Eleanor Reid
- Division of Global Health & International Emergency Medicine, Department of Emergency Medicine, Yale University School of Medicine, New Haven, USA
| | - Michael Lukoma
- Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - Dao Ho
- Memorial Sloane Kettering Hospital, New York, New York, USA
| | - Peace Bagasha
- Makerere Palliative Care Unit, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Mhoira Leng
- Makerere Palliative Care Unit, Mulago Hospital, Makerere University, Kampala, Uganda
- Cairdeas International Palliative Care Trust, Aberdeen, United Kingdom
| | - Liz Namukwaya
- Makerere Palliative Care Unit, Mulago Hospital, Makerere University, Kampala, Uganda
| |
Collapse
|
5
|
Um YW, Jo YH, Kim HE, Kang SH, Han DK, Lee JH, Park I. The Prognostic Value of the Modified Surprise Question in Critically Ill Emergency Department Patients. J Palliat Care 2023:8258597231217947. [PMID: 38031344 DOI: 10.1177/08258597231217947] [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: 12/01/2023]
Abstract
Objective: The initiation of palliative care (PC) in the emergency department (ED) is effective in improving the quality of life for seriously ill patients. This study aimed to evaluate the prognostic value of the modified surprise question (mSQ), "Would you be surprised if this patient died in the next 30 days?" as a trigger for initiating PC in critically ill ED patients. Methods: We conducted a prospective cohort study over a 6-month period in an ED, during which 22 emergency residents answered the mSQ for critically ill ED patients (Korean Triage and Acuity Scale 1 or 2). The primary outcome was the accuracy of the positive mSQ (negative response to the mSQ) in predicting 30-day mortality, and logistic regression analysis was performed to identify the prognostic factors. Results: A total of 300 patients were enrolled, and the positive mSQ group included 118 (39.3%) patients. The 30-day mortality rate of the cohort was 10.0%. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive mSQ were 83.3%, 65.6%, 21.2%, and 97.3%, respectively, with a c-statistic of 0.74 and a positive likelihood ratio of 2.42. In a multivariable analysis controlling for clinically relevant variables, the odds ratio for 30-day mortality of the positive mSQ was 4.76 (95% confidence interval, 1.61-14.09; P = .005). Conclusions: The mSQ may be valuable for identifying critically ill ED patients with an increased risk of 30-day mortality. Therefore, it may be utilized as a trigger for PC consultation in the ED.
Collapse
Affiliation(s)
- Young Woo Um
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Hee Eun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Hyun Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Dong Kwan Han
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| |
Collapse
|
6
|
Collins A, Hui D, Davison SN, Ducharlet K, Murtagh F, Chang YK, Philip J. Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review. J Pain Symptom Manage 2023; 66:541-550.e1. [PMID: 37507095 DOI: 10.1016/j.jpainsymman.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
CONTEXT People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all. OBJECTIVES This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services. METHODS Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751). DATA SOURCES Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses. RESULTS Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%). CONCLUSION Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.
Collapse
Affiliation(s)
- Anna Collins
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia
| | - David Hui
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara N Davison
- Division of Nephrology & Immunology (S.N.D.), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Ducharlet
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Department of Nephrology (K.D.), St Vincent's Hospital, Melbourne, Australia; Eastern Health Clinical School (K.D.), Monash University, Melbourne, Australia; Eastern Health Integrated Renal Services (K.D.), Melbourne, Australia
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre (F.M.), Hull York Medical School, University of Hull, UK
| | - Yuchieh Kathryn Chang
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Philip
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Palliative Care Service (J.P.), Royal Melbourne Hospital, Parkville, Australia; Palliative Care Service (J.P.), Peter MacCallum Cancer Centre, Melbourne, Australia.
| |
Collapse
|
7
|
Prachanukool T, George N, Bowman J, Ito K, Ouchi K. Best Practices in End of Life and Palliative Care in the Emergency Department. Clin Geriatr Med 2023; 39:575-597. [PMID: 37798066 DOI: 10.1016/j.cger.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.
Collapse
Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand; Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA.
| | - Naomi George
- Division of Critical Care Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, 700 Camino de Salud, Albuquerque, NM 87131, USA
| | - Jason Bowman
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA; Department of Psychosocial Oncology and Palliative Medicine, Dana Farber Cancer Institute, 75 Francis Street, Neville House, Boston, MA 02115, USA
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo 173-8606, Japan
| | - Kei Ouchi
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA; Department of Psychosocial Oncology and Palliative Medicine, Dana Farber Cancer Institute, 75 Francis Street, Neville House, Boston, MA 02115, USA
| |
Collapse
|
8
|
DeGroot L, Pavlovic N, Perrin N, Gilotra NA, Dy SM, Davidson PM, Szanton SL, Saylor MA. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. J Pain Symptom Manage 2023; 65:500-509. [PMID: 36736499 PMCID: PMC10192105 DOI: 10.1016/j.jpainsymman.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
CONTEXT Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. OBJECTIVES This study describes the PC needs of community dwelling, physically frail persons with HF. METHODS We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0 = robust, 1-2 = prefrail, 3-5 = frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score = higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. RESULTS Participants (N = 286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). CONCLUSION Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.
Collapse
Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA.
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Johns Hopkins University School of Medicine (N.A.G), Baltimore, Maryland, USA
| | - Sydney M Dy
- Johns Hopkins University School of Public Health (S.M.D), Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| | - Martha Abshire Saylor
- Johns Hopkins University School of Nursing (L.D., N.P., N.P., S.L.S., M.A.S.), Baltimore, Maryland, USA
| |
Collapse
|
9
|
Lee SY, Ro YS, Shin SD, Ko E, Kim SJ. Epidemiology of patients who died in the emergency departments and need of end-of-life care in Korea from 2016 to 2019. Sci Rep 2023; 13:686. [PMID: 36639721 PMCID: PMC9839758 DOI: 10.1038/s41598-023-27947-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
The need of palliative care at the end-of-life in the emergency departments (ED) is growing. The study aims to investigate the epidemiology of patients who died during care in ED using nationwide database, and to estimate the need for palliative care in the ED. A retrospective observational study was conducted using the National Emergency Department Information System (NEDIS) database. Patients who died during ED care between 2016 and 2019 were included. Palliative care-eligible disease was defined as cancer (C00-C99 of ICD-10), chronic respiratory disease (CRD, J44-J46), chronic liver disease (CLD, K70-K77), and heart failure (HF, I50). Among the 36,538,486 ED visits during 4 years, 34,086 ED deaths were included. The crude incidence rate of ED deaths per 100,000 person-year was steady between 16.6 in 2016 and 16.3 in 2019 (p-for-trend = 0.067). Only 3370 (9.9%) ED deaths were injury, while 30,716 (90.1%) deaths were related to diseases. The most common ED diagnosis was cardiac arrest (22.1%), followed by pneumonia (8.6%) and myocardial infarction (4.7%). In cases of disease-related ED deaths, about 34.0% stayed longer than 8 h in the ED (median (interquartile range): 4.5 (1.9-11.7) h) and 44.2% received cardiopulmonary resuscitation (CPR) at end-of-life time. A quarter of the disease-related ED deaths were diagnosed with palliative care eligible disease: cancer (16.9%), CLD (3.8%), HF (3.5%), and CRD (1.4%). Cancer patients received less CPR (23.4%) and stayed longer in the ED (median (interquartile range): 7.3 (3.2-15.9) h). Over the past 4 years, more than 30,000 patients, including 5200 cancer patients, died during care in the ED. A quarter of disease-related ED death were patients with palliative care-eligible condition and more than 30% of them stayed longer than 8 h in the ED before death. It is time to discuss about need of palliative care in the ED.
Collapse
Affiliation(s)
- Sun Young Lee
- grid.412484.f0000 0001 0302 820XPublic Healthcare Center, Seoul National University Hospital, Seoul, Korea ,grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.31501.360000 0004 0470 5905Department of Medicine, Seoul National University college of Medicine, Seoul, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea. .,Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Korea. .,Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea. .,National Emergency Medical Center, National Medical Center, Seoul, Korea.
| | - Sang Do Shin
- grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.412484.f0000 0001 0302 820XDepartment of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Korea ,grid.31501.360000 0004 0470 5905Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eunsil Ko
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Seong Jung Kim
- National Emergency Medical Center, National Medical Center, Seoul, Korea. .,Department of Emergency Medicine, Chosun University Hospital, 365 Pilmun-Daero, Dong-Gu, Gwangju, 61453, Korea.
| |
Collapse
|
10
|
Benesch TD, Moore JE, Breyre AM, DeWitt R, Nattinger CC, Dellinger E, Anderson ES, Bulman L. Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention. AEM EDUCATION AND TRAINING 2022; 6:e10823. [PMID: 36562021 PMCID: PMC9763971 DOI: 10.1002/aet2.10823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 05/31/2023]
Abstract
Background Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Methods Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM. Results The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use. Conclusions An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.
Collapse
Affiliation(s)
| | | | - Amelia M. Breyre
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Raizel DeWitt
- Joint Medical ProgramUniversity of California, Berkeley and University of California, San FranciscoCaliforniaBerkeleyUSA
| | - Caroline C. Nattinger
- Joint Medical ProgramUniversity of California, Berkeley and University of California, San FranciscoCaliforniaBerkeleyUSA
| | | | | | - Linda Bulman
- Alameda Health SystemHighland HospitalOaklandCaliforniaUSA
| |
Collapse
|
11
|
Waller A, Hobden B, Fakes K, Clark K. A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease. Front Cardiovasc Med 2022; 9:878428. [PMID: 35498028 PMCID: PMC9043454 DOI: 10.3389/fcvm.2022.878428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice. Aims This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice. Methods Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria. Results Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice. Conclusion Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.
Collapse
Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- *Correspondence: Amy Waller
| | - Breanne Hobden
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Kristy Fakes
- Health Behaviour Research Collaborative, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Katherine Clark
- Northern Sydney Local Health District (NSLHD) Supportive and Palliative Care Network, St Leonards, NSW, Australia
- Northern Clinical School, The University of Sydney, Darlington, NSW, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| |
Collapse
|
12
|
Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
Collapse
Affiliation(s)
- Emily L. Aaronson
- Department of Emergency Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | | | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Mongan Institute Center for Aging and Serious Illness Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center New York New York USA
| | - Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York New York USA
| | - Jason K. Bowman
- Department of Emergency Medicine Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Joanne G. Kuntz
- Department of Palliative and Supportive Care Emory University Hospital Midtown, Emory University School of Medicine Atlanta Georgia USA
| | - Kei Ouchi
- Department of Emergency Medicine Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Karen Jubanyik
- Emergency Department Yale University School of Medicine New Haven Connecticut USA
| | - Leah E. Bright
- Department of Emergency Medicine Johns Hopkins Hospital Baltimore Maryland USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - Eric Isaacs
- Emergency Department Zuckerberg San Francisco General Hospital, University of California at San Francisco San Francisco California USA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis St. Louis Missouri USA
- Department of Emergency Medicine Rutgers New Jersey Medical School Newark New Jersey USA
| | - Rebecca Goett
- Department of Emergency Medicine Rutgers New Jersey Medical School Newark New Jersey USA
| | - Lauren LaPointe
- Department of Social Work Massachusetts General Hospital Boston Massachusetts USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine Seattle Washington USA
| | - Rita Manfredi
- Department of Emergency Medicine The George Washington University School of Medicine Washington DC USA
| | - Tammie Quest
- Department of Palliative and Supportive Care Emory University Hospital Midtown, Emory University School of Medicine Atlanta Georgia USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
| |
Collapse
|
13
|
Palliative Care in Older People with Multimorbidities: A Scoping Review on the Palliative Care Needs of Patients, Carers, and Health Professionals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063195. [PMID: 35328881 PMCID: PMC8954932 DOI: 10.3390/ijerph19063195] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 12/30/2022]
Abstract
Although numerous studies have been conducted previously on the needs of cancer patients at the end of their life, there is a lack of studies focused on older patients with non-oncological complex chronic multipathologies. Examining these needs would help to gain a greater understanding of the profile of this specific population within the palliative care (PC) pathway and how the health and care systems can address them. The aim of this review was to identify the needs influencing PC among older patients with multimorbidities, their relatives or informal caregivers, and the health professionals who provide care for these patients. A scoping literature review guided by the Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was carried out with literature searched in the Medline, Embase, CINAHL, WoS, Cochrane Library, PsycINFO, and Scopus databases from 2009 to 2022. Eighty-one studies were included, demonstrating a great variety of unaddressed needs for PC among chronic older patients and the complexity in detecting those needs and how to refer them to PC pathways. This review also suggested a scarcity of tools and limited pathways for professionals to satisfy their needs for these patients and their families, who often felt ignored by the system. Substantial changes will be needed in health and care systems at the institutional level, providing more specialized PC environments and systematizing PC processes.
Collapse
|
14
|
Huh JY, Matsuoka Y, Kinoshita H, Ikenoue T, Yamamoto Y, Ariyoshi K. Premorbid Clinical Frailty Score and 30‐day mortality among older adults in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12677. [PMID: 35224550 PMCID: PMC8847731 DOI: 10.1002/emp2.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/03/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives The association between frailty and short‐term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30‐day mortality in this patient population. Methods This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out‐of‐hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients’ chart reviews. The primary outcome was 30‐day mortality, and we examined the association between frailty scored on the CFS and 30‐day mortality using a multivariable logistic regression model with CFS 1–4 as a reference. Results A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30‐day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7–9 was 6.3% (‐3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively. Conclusion The risk of 30‐day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short‐term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.
Collapse
Affiliation(s)
- Ji Young Huh
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
| | - Yoshinori Matsuoka
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
- Department of Healthcare Epidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Hiroki Kinoshita
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
| | - Tatsuyoshi Ikenoue
- Department of Human Health Science Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
| |
Collapse
|
15
|
Han G, Bohmart A, Shaaban H, Mages K, Jedlicka C, Zhang Y, Steel P. Emergency Department Utilization Among Maintenance Hemodialysis Patients: A Systematic Review. Kidney Med 2021; 4:100391. [PMID: 35243303 PMCID: PMC8861946 DOI: 10.1016/j.xkme.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Gregory Han
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY
- Address for Correspondence: Gregory Han, BA, Department of Emergency Medicine, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065.
| | - Andrew Bohmart
- The Rogosin Institute, Weill Cornell Medicine, New York, NY
| | - Heba Shaaban
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY
| | - Keith Mages
- Robert L. Brown History of Medicine Collection, University at Buffalo, Buffalo, NY
| | - Caroline Jedlicka
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY
| | - Yiye Zhang
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY
| | - Peter Steel
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY
| |
Collapse
|
16
|
Chang JCY, Yang C, Lai LL, Huang HH, Tsai SH, Hsu TF, Yen DHT. Differences in Characteristics, Hospital Care, and Outcomes between Acute Critically Ill Emergency Department Patients Receiving Palliative Care and Usual Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312546. [PMID: 34886271 PMCID: PMC8656613 DOI: 10.3390/ijerph182312546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.
Collapse
Affiliation(s)
- Julia Chia-Yu Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (C.Y.); (L.-L.L.)
| | - Li-Ling Lai
- Department of Nursing, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (C.Y.); (L.-L.L.)
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Teh-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Emergency Medicine, National Defense Medical Center, Taipei 11490, Taiwan;
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 30015, Taiwan
- Correspondence:
| |
Collapse
|
17
|
A missed opportunity in the ED: Palliative care consult delays during inpatient admission. Am J Emerg Med 2021; 51:325-330. [PMID: 34800905 DOI: 10.1016/j.ajem.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 11/22/2022] Open
Abstract
STUDY HYPOTHESIS Although Emergency Medicine has recognized Palliative Care (PC) as an important aspect of Emergency Medicine, the importance of integrating palliative care into standard practice is underscored by the data that many patients qualify for PC but are not utilizing this part of medicine. We believe Emergency Medicine should integrate Palliative Care as our responsibility and not rely on our colleagues. To support our statement, we undertook an examination of patients who died while inpatient to identify whether they were appropriately receiving palliative care consults. We hypothesized that palliative care is under-utilized for patients during these admissions. DESIGN, SETTING, AND PARTICIPANT Retrospective chart review from 2015 to 2018 of inpatient deaths using an Emergency Medicine Palliative Care Screening Tool to determine qualification for Palliative Care. Setting is John Hopkins Hospital. Participants were age 18 and over; who died during their inpatient admission. MAIN OUTCOMES AND MEASURES Percentage of patients who qualified for palliative care via the screening tool versus percentage of patients who had palliative care involvement. RESULTS The final study sample included 428 patients who died inpatient in the hospital between January 2015 and December 2018. The analysis used a Palliative Care Screening Tool to determine which patients would have qualified for palliative care. Analysis demonstrates that 66% of patients qualified for palliative care, whereas only 27% received it. CONCLUSION AND RELEVANCE The data reflects the percentage of patients who qualified for Palliative Care compared to the definite number of patients who received palliative care. The discrepancy in the percentages support our statement Emergency Medicine should take the lead on initiating palliative care for qualifying patients.
Collapse
|
18
|
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
|
19
|
Fadol AP, Patel A, Shelton V, Krause KJ, Bruera E, Palaskas NL. Palliative care referral criteria and outcomes in cancer and heart failure: a systematic review of literature. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2021; 7:32. [PMID: 34556191 PMCID: PMC8459494 DOI: 10.1186/s40959-021-00117-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/09/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cardiotoxicity resulting in heart failure (HF) is among the most dreaded complications of cancer therapy and can significantly impact morbidity and mortality. Leading professional societies in cardiology and oncology recommend improved access to hospice and palliative care (PC) for patients with cancer and advanced HF. However, there is a paucity of published literature on the use of PC in cardio-oncology, particularly in patients with HF and a concurrent diagnosis of cancer. AIMS To identify existing criteria for referral to and early integration of PC in the management of cases of patients with cancer and patients with HF, and to identify assessments of outcomes of PC intervention that overlap between patients with cancer and patients with HF. DESIGN Systematic literature review on PC in patients with HF and in patients with cancer. DATA SOURCES Databases including Ovid Medline, Ovid Embase, Cochrane Library, and Web of Science from January 2009 to September 2020. RESULTS Sixteen studies of PC in cancer and 14 studies of PC in HF were identified after screening of the 8647 retrieved citations. Cancer and HF share similarities in their patient-reported symptoms, quality of life, symptom burden, social support needs, readmission rates, and mortality. CONCLUSION The literature supports the integration of PC into oncology and cardiology practices, which has shown significant benefit to patients, caregivers, and the healthcare system alike. Incorporating PC in cardio-oncology, particularly in the management of HF in patients with cancer, as early as at diagnosis, will enable patients, family members, and healthcare professionals to make informed decisions about various treatments and end-of-life care and provide an opportunity for patients to participate in the decisions about how they will spend their final days.
Collapse
Affiliation(s)
- Anecita P Fadol
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ashley Patel
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Valerie Shelton
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicolas L Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
20
|
Willert AC, Ploner CJ, Kowski AB. Causes for Emergency Hospitalization of Neurological Patients With Palliative Care Needs. Front Neurol 2021; 12:674114. [PMID: 34408720 PMCID: PMC8365085 DOI: 10.3389/fneur.2021.674114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Acute and unexpected hospitalization can cause serious distress, particularly in patients with palliative care needs. Nevertheless, the majority of neurological inpatients receiving palliative care are admitted via an emergency department. Objective: Identification of potentially avoidable causes leading to acute hospitalization of patients with neurological disorders or neurological symptoms requiring palliative care. Methods: Retrospective analysis of medical records of all patients who were admitted via the emergency department and received palliative care in a neurological ward later on (n = 130). Results: The main reasons for acute admission were epileptic seizures (22%), gait disorders (22%), disturbance of consciousness (20%), pain (17%), nutritional problems (17%), or paresis (14%). Possible therapy limitations, (non)existence of a patient decree, or healthcare proxy was documented in only 31%. Primary diagnoses were neoplastic (49%), neurodegenerative (30%), or cerebrovascular (18%) diseases. Fifty-nine percent were directly admitted to a neurological ward; 25% needed intensive care. On average, it took 24 h until the palliative care team was involved. In contrast to initially documented problems, key challenges identified by palliative care assessment were psychosocial problems. For 40% of all cases, a specialized palliative care could be organized. Conclusion: Admissions were mainly triggered by acute events. Documentation of the palliative situation and treatment limitations may help to prevent unnecessary hospitalization. Although patients present with a complex symptom burden, emergency department assessment is not able to fully address multidimensionality, especially concerning psychosocial problems. Prospective investigations should develop short screening tools to identify palliative care needs of neurological patients already in the emergency department.
Collapse
Affiliation(s)
| | - Christoph J Ploner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander B Kowski
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
21
|
Oncological Assistance in the Emergency Room Setting: The Role of a Dedicated Oncology Unit. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.110512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The appearance of symptoms that may be related to the worsening of the disease, as well as the toxicity of chemotherapy treatment or an acute complication, are the most frequent reasons for access to the emergency room (ER) for patients with cancer. To date, the Italian territorial health services, as well as local preventive medicine, are unable to provide adequate management of patients with cancer and, for this reason, diagnostic delays and inappropriate hospitalization in the oncology departments have occurred; moreover, it has been observed that many patients receive the first diagnosis of cancer directly in the ER, where the experience in the oncology field is often inadequate. Objectives: Cardarelli Hospital, in Naples, started twenty-two month Experimental Oncological Emergency Service, under the supervision of its own Oncology Department, with the double main objectives of encouraging de-hospitalization and improving diagnostic and therapeutic performance. Methods: We have developed a methodological protocol for patients’ admission to the ER, assuming that the host physician transfers patients with suspected cancer to a new hospital figure, the ER oncologist, who acts as supervisor and coordinator. The first consultation was carried out together with one or more specialists, identified by the supervisor. Based on their characteristics, the patients were divided into 4 categories: (1) Patients with a known diagnosis of cancer and already undergoing anticancer treatments; (2) patients who show complications due to ongoing cancer treatments; (3) patients who no longer respond to anticancer treatments due to the worsening of the disease; (4) patients who are first diagnosed with cancer in the ER. Each individual cohort of patients was directed towards what we have called diagnostic-therapeutic assistance paths (PDTA), specific protocols for each type of patient, which allowed us to reduce the time to diagnosis. Results: According to the data, the average hospitalization time for patients with lung cancer who followed the study was 10 days, compared to 16 days for patients who did not undergo cancer screening in the ER. Another relevant result demonstrated the improvement in the quality and efficiency of medical services by including first aid in the management of cancer patients regards de-hospitalization. In fact, thanks to the experimental protocol we applied, we were able to de-hospitalize 484 patients directly from the ER, which are over 34% of the total. Conclusions: Close integration between hospital medical fields and territorial medicine could improve the quality of cancer treatment and the efficiency of health services management. All of this without affecting the costs of public healthcare because of the considerable improvement in performance which allowed important savings.
Collapse
|
22
|
Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med 2021; 78:658-669. [PMID: 34353647 DOI: 10.1016/j.annemergmed.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.
Collapse
Affiliation(s)
- Anthony J Loffredo
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA
| | - David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, CA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Eric D Isaacs
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Rachel Pearl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Rosenberg
- Department of Emergency Medicine, St Joseph's Health, Paterson and Wayne, NJ
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St Joseph's Health, Paterson, NJ; Department of Emergency Medicine, Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| |
Collapse
|
23
|
Kruhlak M, Kirkland SW, Clua MG, Villa-Roel C, Elwi A, O'Neill B, Duggan S, Brisebois A, Rowe BH. An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study. J Palliat Med 2021; 24:1840-1848. [PMID: 34255578 DOI: 10.1089/jpm.2021.0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ2 tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.
Collapse
Affiliation(s)
- Maureen Kruhlak
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott W Kirkland
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adam Elwi
- Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Shelley Duggan
- Department of Medicine and Palliative Care, Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Department of Medicine and Palliative Care, Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
24
|
Bringing Palliative Care Downstairs: A Case-Based Approach to Applying Palliative Care Principles to Emergency Department Practice. Adv Emerg Nurs J 2021; 42:215-224. [PMID: 32739951 DOI: 10.1097/tme.0000000000000307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although the emergency department (ED) may not be traditionally thought of as the ideal setting for the initiation of palliative care, it is the place where patients most frequently seek urgent care for recurrent issues such as pain crisis. Even if the patients' goals of care are nonaggressive, their caregivers may bring them to the ED because of their own distress at witnessing the patients' suffering. Emergency department providers, who are trained to focus on the stabilization of acute medical crises, may find themselves frustrated with repeat visits by patients with chronic problems. Therefore, it is important for ED providers to be comfortable discussing goals of care, to be adept at symptom management for chronic conditions, and to involve palliative care consultants in the ED course when appropriate. Nurse practitioners, with training rooted in the holistic tradition of nursing, may be uniquely suited to lead this shift in the practice paradigm. This article presents case vignettes of 4 commonly encountered ED patient types to examine how palliative care principles might be applied in the ED.
Collapse
|
25
|
Bright L, Marr B. Clinical Relevance and Considerations of Palliative Care in Older Adults. Emerg Med Clin North Am 2021; 39:443-452. [PMID: 33863471 DOI: 10.1016/j.emc.2021.01.007] [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: 11/25/2022]
Abstract
The incorporation of palliative care to address the needs of the older adult is a vital part of emergency medicine. Recognizing the trajectory of chronic diseases in older adults and the myriad of medical diseases amenable to palliative care is paramount. Early involvement of palliative care should be considered the cornerstone to overarching management of the older adult presenting to the emergency department.
Collapse
Affiliation(s)
- Leah Bright
- Emergency Medicine Department, Johns Hopkins Hospital, 1830 East Monument Street, Baltimore, MD 21287, USA.
| | - Bonnie Marr
- The Johns Hopkins Hospital, 600 N. Wolfe Street, Section of Palliative Medicine, Blalock 359, Baltimore, MD 21287, USA
| |
Collapse
|
26
|
Hsu HS, Wu TH, Lin CY, Lin CC, Chen TP, Lin WY. Enhanced home palliative care could reduce emergency department visits due to non-organic dyspnea among cancer patients: a retrospective cohort study. BMC Palliat Care 2021; 20:42. [PMID: 33714277 PMCID: PMC7956106 DOI: 10.1186/s12904-021-00713-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/11/2021] [Indexed: 11/21/2022] Open
Abstract
Background Dyspnea is a common trigger of emergency department visits among terminally ill and cancer patients. Frequent emergency department (ED) visits at the end of life are an indicator of poor-quality care. We examined emergency department visit rates due to dyspnea symptoms among palliative patients under enhanced home palliative care. Methods Our home palliative care team is responsible for patient management by palliative care specialists, residents, home care nurses, social workers, and chaplains. We enhanced home palliative care visits from 5 days a week to 7 days a week, corresponding to one to two extra visits per week based on patient needs, to develop team-based medical services and formulate standard operating procedures for dyspnea care. Results Our team cared for a total of 762 patients who exhibited 512 ED visits, 178 of which were due to dyspnea (mean ± SD age, 70.4 ± 13.0 years; 49.4% male). Dyspnea (27.8%) was the most common reason recorded for ED visits, followed by pain (19.0%), GI symptoms (15.7%), and fever (15.3%). The analysis of Group A versus Group B revealed that the proportion of nonfamily workers (42.9% vs. 19.4%) and family members (57.1% vs. 80.6%) acting as caregivers differed significantly (P < 0.05). Compared to the ED visits of the Group A, the risk was decreased by 30.7% in the Group B (P < 0.05). Conclusions This study proves that enhanced home palliative care with two additional days per week and formulated standard operating procedures for dyspnea could significantly reduce the rate of ED visits due to non-organic dyspnea during the last 6 months of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00713-6.
Collapse
Affiliation(s)
- Hua-Shui Hsu
- Department of Family Medicine and Social Medicine, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Palliative Medicine, China Medicinal University Hospital, Taichung, Taiwan.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Tai-Hsien Wu
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chin-Yu Lin
- Department of Nursing, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Chun Lin
- Department of Family Medicine and Social Medicine, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Palliative Medicine, China Medicinal University Hospital, Taichung, Taiwan
| | - Tsung-Po Chen
- Department of Family Medicine and Social Medicine, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Palliative Medicine, China Medicinal University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- Department of Family Medicine and Social Medicine, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan. .,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan. .,Department of Palliative Medicine, China Medicinal University Hospital, Taichung, Taiwan.
| |
Collapse
|
27
|
Amado-Tineo JP, Oscanoa-Espinoza T, Vásquez-Alva R, Huari-Pastrana R, Delgado-Guay MO. Emergency Department Use by Terminally Ill Patients: A Systematic Review. J Pain Symptom Manage 2021; 61:531-543. [PMID: 32822748 DOI: 10.1016/j.jpainsymman.2020.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 01/15/2023]
Abstract
CONTEXT Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear. OBJECTIVE To determine the prevalence of TIP visiting the ED. METHODS Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I2). RESULTS We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37-54%] and 75% in the last six months of life [95% CI 62-83%]; I2 = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12-23%]; I2 = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping. CONCLUSIONS Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.
Collapse
Affiliation(s)
- José P Amado-Tineo
- Emergency Department of Rebagliati Hospital EsSalud, Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru.
| | - Teodoro Oscanoa-Espinoza
- Medicine Department of Almenara Hospital EsSalud, Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Rolando Vásquez-Alva
- Emergency Department of Rebagliati Hospital EsSalud, Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Roberto Huari-Pastrana
- Emergency Department of Rebagliati Hospital EsSalud, Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Marvin O Delgado-Guay
- Department of Palliative Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
28
|
Oğuz G, Koçak N, Şenel G, Kadioğullari N. Characteristics of Advanced Cancer Patients Admitted to the Palliative Care Unit from the Emergency Department. Indian J Palliat Care 2021; 27:89-94. [PMID: 34035623 PMCID: PMC8121232 DOI: 10.4103/ijpc.ijpc_126_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/01/2020] [Accepted: 10/02/2020] [Indexed: 11/05/2022] Open
Abstract
Aim: People with cancer frequently present to emergency departments (EDs) because of exacerbation of the existing problems and new symptoms, complications of treatments, or difficulties with care and support systems. The aim of the study was to determine the presenting symptoms and demographic characteristics of advanced cancer patients and their caregivers admitted to the palliative care (PC) unit from the ED. Methods: After approval, 139 cancer patients admitted to the ED and referred for PC consultation were included in the study. The medical records of PC unit for all patients and their primary caregivers were retrospectively evaluated. Demographic characteristics, cancer site and metastasis, reasons and frequency for ED admissions, symptoms, duration of hospitalization, and outcomes were recorded. The association between the characteristics of caregivers and emergency visits was also evaluated. Results: Among all patients, 61.9% were >60 years old, 58.3% were male, and 71.2% were married. The most frequent site of cancer was gastrointestinal system (39.6%), lungs (18.7%), and genitourinary system (12.2%). The reasons for emergency visits were found as inadequate symptom control (65.5%), dying patient (30.2%), lack of psychosocial support (3.6%), and symptom of other comorbidities (0.7%). The most frequent symptoms were feeling of not well-being, tiredness, and lack of appetite. There was no difference in the number of admissions according to caregivers. Ninety-seven patients (69.8%) died at the PC unit and 42 (30.2%) were discharged. Conclusion: PC system needs to be integrated into all health-care disciplines including EDs. While improving a community- and home-based PC, education of patients, caregivers, and health professionals must also be provided.
Collapse
Affiliation(s)
- Gonca Oğuz
- Department of Anesthesiology, Palliative Care Unit, University of Health Sciences, Dr. AY Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Nesteren Koçak
- Department of Anesthesiology, Palliative Care Unit, University of Health Sciences, Dr. AY Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Gülçin Şenel
- Department of Anesthesiology, Palliative Care Unit, University of Health Sciences, Dr. AY Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Nihal Kadioğullari
- Department of Anesthesiology, Palliative Care Unit, University of Health Sciences, Dr. AY Ankara Oncology Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
29
|
Wang RF, Lai CC, Fu PY, Huang YC, Huang SJ, Chu D, Lin SP, Chaou CH, Hsu CY, Chen HH. A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department. Palliat Med 2021; 35:408-416. [PMID: 33198575 DOI: 10.1177/0269216320972041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM We developed a screening model for predicting 1-year mortality. DESIGN A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.
Collapse
Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taipei
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
| | - Ping-Yeh Fu
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | | | | | - Dachen Chu
- Superintendent, Taipei City Hospital
- National Yang-Ming University, Taipei
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan City
| | - Chen-Yang Hsu
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
- Da-Chung Hospital, Miaoli
| | - Hsiu-Hsi Chen
- Division Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| |
Collapse
|
30
|
Bakan G, Ozen M, Azak A, Erdur B. Determination of the characteristics and outcomes of the palliative care patients admitted to the emergency department. Int Emerg Nurs 2020; 53:100934. [PMID: 33035881 DOI: 10.1016/j.ienj.2020.100934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 09/09/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Terminally ill patients in need of palliative care present to emergency departments. This study aims to identify the usage level of the emergency departments by patients in need of palliative care, along with their experienced symptoms, preferences, needs, and the subsequent initiatives taken for symptom management. METHODS The study was designed as a cross-sectional study and conducted with a group of 208 patients. The Patient Information Form, the Form of the Criteria for Receiving Palliative Care, and the Karnofsky Performance Scale were used for data collection. RESULTS This report founda thatcancer patients were the most frequent users of emergency facilities within palliative care patient groups and more than half of those hospitalized patients were subsequently admitted to intensive care units. Patients with poorer functional conditions and in need of further palliative care preferred home care rather than receiving Advanced Cardiac Life Support. CONCLUSION This study displays evidence that palliative care patients with a poorer functional condition in need of further palliative care should be able to spend the last days of their lives at home with their families rather than in the exhausting and crowded environment of the emergency departments. Furthermore, healthcare policymakers should actively support palliative care as well as taking the necessary actions to mitigate the burden placed on hospital resources.
Collapse
Affiliation(s)
- Gulcan Bakan
- Internal Medicine Nursing Department, Faculty of Health Sciences, Pamukkale University, Kinikli Campus, Denizli, Turkey.
| | - Mert Ozen
- Department of Emergency Medicine, Faculty of Medicine, Pamukale University, Kinikli Campus, Denizli, Turkey
| | - Arife Azak
- Internal Medicine Nursing Department, Faculty of Health Sciences, Pamukkale University, Kinikli Campus, Denizli, Turkey.
| | - Bulent Erdur
- Department of Emergency Medicine, Faculty of Medicine, Pamukale University, Kinikli Campus, Denizli, Turkey.
| |
Collapse
|
31
|
Woods EJ, Ginsburg AD, Bellolio F, Walker LE. Palliative care in the emergency department: A survey assessment of patient and provider perspectives. Palliat Med 2020; 34:1279-1285. [PMID: 32666881 DOI: 10.1177/0269216320942453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care has been identified as an area of low outpatient referral from our emergency department, yet palliative care has been shown to improve the quality of patient's lives. AIM This study investigates both provider and patient perspectives on palliative care for the purpose of identifying barriers to increased palliative care utilization within our healthcare system. DESIGN Two surveys were developed, one for patients/caregivers and one for healthcare providers. SETTING/PARTICIPANTS This was a single-center study completed at a quaternary academic emergency department. A survey was sent to emergency medicine providers with 47% response rate. Research staff approached Emergency Department patients who had been identified to be high risk to fill out paper surveys with 76% response rate. RESULTS Only 28% of patients had already undergone palliative care, with an additional 25% interested in palliative care. Nearly half of the patients felt that they needed more resources to prevent hospital visits. Patients identified low understanding of palliative care and difficulty accessing appointments as barriers to consultation. Among providers, 98% indicated that they had patients who would benefit from palliative care. A majority of providers highlighted patient understanding of palliative care and access to appointments as barriers to palliative care. Notably, 52% of providers reported that emergency medicine provider knowledge was a barrier to palliative care consultation. CONCLUSIONS Despite emergency department patients' self-identified need for resources and emergency medicine providers' recognition of patients who would benefit from palliative care, few patients receive palliative care consultation.
Collapse
Affiliation(s)
- Emily J Woods
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
32
|
Wang DH, Heidt R. Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs. J Palliat Med 2020; 24:554-560. [PMID: 32897797 DOI: 10.1089/jpm.2020.0082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Emergency department (ED) initiated palliative consultation impacts downstream care utilization. Various admission consult triggers have been proposed without clear best practice or outcomes. Objective: This 18-month single-center study evaluated the clinical, operational, and financial impact of simplified admission triggers for ED-initiated palliative consults as compared to downstream Floor and intensive care unit (ICU) palliative consults initiated per usual practice. Methods: We distilled ED admission triggers into three criteria to ensure bedside actionability and sustainability: (1) end-stage illness, (2) functional limitation, and (3) clinician would not be surprised if the patient died this hospitalization. Eligible patients met all criteria, and received consultation within 24 hours of admission. We compared ED-initiated consults against Floor and ICU consults from March 1, 2018, to September 30, 2019, with matched cohort analysis to evaluate financial outcomes. Results: While overall palliative consult volume remained intentionally steady, the proportion of ED-initiated consults significantly increased (7% vs. 19%, p < 0.001). ED consistently comprised 15-25% of all monthly palliative consults. Compared with Floor, ED had similar ED length of stay (LOS) and inpatient mortality. Among live discharges, ED were more likely to be referred to hospice than Floor (59% vs. 47%, p = 0.24) or ICU (59% vs. 34%, p = 0.02). In a matched cohort analysis, ED demonstrated median cost avoidance of $9,082 per patient versus Floor ($5,578 vs. $14,660, p < 0.001) and $15,138 per patient versus ICU ($5,578 vs. $20,716, p < 0.001). ED had significantly shorter median LOS before consult than Floor (0 vs. 3 days, p < 0.001) or ICU (0 vs. 3 days, p < 0.001), which did not differ between live discharges or inpatient deaths. Overall hospital LOS was disproportionately shorter for ED, with a net difference-in-differences of 1-3.5 days compared to Floor and ICU. Conclusions: Simple ED admission triggers to expedite palliative engagement are associated with a 50-75% reduction in both hospital LOS and costs when compared against usual palliative consultation practice. ED initiation reduces both lead time before consultation and subsequent downstream hospitalization length.
Collapse
Affiliation(s)
- David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, California, USA
| | - Ryan Heidt
- Division of Palliative Medicine, Scripps Health, San Diego, California, USA
| |
Collapse
|
33
|
DeGroot L, Koirala B, Pavlovic N, Nelson K, Allen J, Davidson P, Abshire M. Outpatient Palliative Care in Heart Failure: An Integrative Review. J Palliat Med 2020; 23:1257-1269. [PMID: 32522132 PMCID: PMC7469696 DOI: 10.1089/jpm.2020.0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Early integration of palliative care (PC) for patients with heart failure (HF) improves patient outcomes and decreases health care utilization. PC provided outside of an acute hospitalization is not well understood. Objective: To synthesize the literature of outpatient PC in HF to identify the current landscape, the impact on patient health outcomes, key stakeholders' perspectives, and future implications for research and practice. Design: A systematic search of PubMed, Embase, CINAHL, Cochrane, and Web of Science was conducted from inception to February 2019 for studies of outpatient PC in adults with HF. Each study was analyzed to describe study characteristics, location of PC, types of providers involved, participant characteristics, and main findings, and to characterize domains of PC addressed. Results: Most studies (N = 19) employed a quantitative design and were conducted in the United States. The most common locations of PC were the home or PC clinic and providers were mainly PC specialists. Outpatient PC improved quality of life, alleviated symptoms, and decreased rehospitalizations for patients with HF. No study addressed all eight domains of PC. The structural, physical, and psychological domains were commonly addressed, whereas, least commonly addressed domains were the cultural and ethical/legal domain. Women and ethnic minorities were underrepresented in the majority of samples. Conclusions: This integrative review highlights the need to promote primary PC and future PC research focusing on a holistic, integrated, team-based approach addressing all domains of PC in representative samples.
Collapse
Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Binu Koirala
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Katie Nelson
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Jerilyn Allen
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Patricia Davidson
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Martha Abshire
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Huang YL, Alsaba N, Brookes G, Crilly J. Review article: End-of-life care for older people in the emergency department: A scoping review. Emerg Med Australas 2019; 32:7-19. [PMID: 31820582 DOI: 10.1111/1742-6723.13414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/14/2019] [Accepted: 10/20/2019] [Indexed: 12/22/2022]
Abstract
Older people are increasingly utilising emergency services, often at the end of their life. This scoping review aimed to provide a comprehensive understanding of available research regarding end-of-life (EOL) care for older people in the ED. The Joanna Briggs Institute scoping review methodology guided this review. Databases of CINAHL, Ovid MEDLINE, Embase, SocINDEX and Google Scholar were searched using a combination of terms, including older/aged/geriatrics/elderly, palliative/terminal/end-of-life and emergency/emergency service. The search was limited to articles published in English from 2007 to 2018. The level of evidence of included articles was assessed using the National Health and Medical Research Council (NHMRC) criteria. Fourteen articles were included. Definitions pertaining to EOL care in the ED vary. Older people presenting to ED at EOL were mostly female, triaged in urgent or semi-urgent category, presented with diagnoses of advanced cancer, cardiac and pulmonary disease, and dementia with symptoms including pain and breathlessness. Multiple tools pertaining to EOL exist and range from predicting mortality, and assessing functional status, co-morbidities, symptom distress, palliative care needs, quality of life and caregiver's stress. Outcomes for older people enrolled in specific EOL intervention programmes included lower admission rates, shorter ED length of stay, increased palliative care referral and consultations, and decreased Medicare costs. The NHMRC evidence level of included articles ranged from II to IV. Limited evidence exists regarding the definition, clinical profile, care delivery and outcomes for older people requiring EOL care in the ED. Future research and clinical practice that uses current evidenced-based policies and guidelines is required.
Collapse
Affiliation(s)
- Ya-Ling Huang
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Nemat Alsaba
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
| | - Gemma Brookes
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
36
|
Di Leo S, Alquati S, Autelitano C, Costantini M, Martucci G, De Vincenzo F, Kuczynska B, Morini A, Trabucco L, Ursicelli R, Catania G, Ghirotto L. Palliative care in the emergency department as seen by providers and users: a qualitative study. Scand J Trauma Resusc Emerg Med 2019; 27:88. [PMID: 31533807 PMCID: PMC6751856 DOI: 10.1186/s13049-019-0662-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals’ and users’ perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments. Methods A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis. Results Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care. Conclusions This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.
Collapse
Affiliation(s)
- Silvia Di Leo
- Psycho-oncology Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Sara Alquati
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cristina Autelitano
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gianfranco Martucci
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Beata Kuczynska
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Morini
- Day Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Laura Trabucco
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Raffaella Ursicelli
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gianluca Catania
- Department of Health Sciences, University of Genoa, Genova, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| |
Collapse
|
37
|
Reuter Q, Marshall A, Zaidi H, Sista P, Powell ES, McCarthy DM, Dresden SM. Emergency Department-Based Palliative Interventions: A Novel Approach to Palliative Care in the Emergency Department. J Palliat Med 2019; 22:649-655. [DOI: 10.1089/jpm.2018.0341] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Quentin Reuter
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alison Marshall
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Hashim Zaidi
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Priyanka Sista
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emilie S. Powell
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Danielle M. McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Scott M. Dresden
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
38
|
Bell D, Ruttenberg MB, Chai E. Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department. Clin Geriatr Med 2019; 34:453-467. [PMID: 30031427 DOI: 10.1016/j.cger.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.
Collapse
Affiliation(s)
- Daniel Bell
- Department of Emergency Medicine, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
| | - Margaret Brungraber Ruttenberg
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Emily Chai
- Geriatrics and Palliative Medicine Inpatient Services, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1970, New York, NY 10029, USA
| |
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
Palliative care in emergency medicine: A perennial skill with a new emphasis. CAN J EMERG MED 2019; 21:163-164. [DOI: 10.1017/cem.2019.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
41
|
Koh MY, Lee JF, Montalban S, Foo CL, Hum AY. ED-PALS: A Comprehensive Palliative Care Service for Oncology Patients in the Emergency Department. Am J Hosp Palliat Care 2019; 36:571-576. [DOI: 10.1177/1049909119825847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Mervyn Y.H. Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
| | - Jia F. Lee
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Socrates Montalban
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chik L. Foo
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Y.M. Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
| |
Collapse
|
42
|
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.
Collapse
|
43
|
Leyenaar JK, Bogetz JF. Child Mortality in the United States: Bridging Palliative Care and Public Health Perspectives. Pediatrics 2018; 142:peds.2018-1927. [PMID: 30232218 DOI: 10.1542/peds.2018-1927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics, The Dartmouth Institute For Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; and
| | - Jori F Bogetz
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| |
Collapse
|
44
|
Flieger SP, Spatz E, Cherlin EJ, Curry LA. Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning. Am J Hosp Palliat Care 2018; 36:97-104. [PMID: 30122054 DOI: 10.1177/1049909118794149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. OBJECTIVE: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. METHODS: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. RESULTS: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. CONCLUSIONS: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.
Collapse
Affiliation(s)
- Signe Peterson Flieger
- 1 Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Erica Spatz
- 2 Yale School of Medicine, New Haven, CT, USA
| | - Emily J Cherlin
- 3 Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, CT, USA
| | - Leslie A Curry
- 3 Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, CT, USA
| |
Collapse
|
45
|
|
46
|
A position paper: The convergence of aging and injury and the need for a Geriatric Trauma Coalition (GeriTraC). J Trauma Acute Care Surg 2018; 82:419-422. [PMID: 27893640 DOI: 10.1097/ta.0000000000001317] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
47
|
Quality of life, symptoms and care needs in patients with persistent or recurrent platinum-resistant ovarian cancer: An NRG Oncology/Gynecologic Oncology Group study. Gynecol Oncol 2018; 150:119-126. [PMID: 29778506 DOI: 10.1016/j.ygyno.2018.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The goals of treating recurrent platinum-resistant ovarian cancer are palliative, aimed at reducing symptoms and improving progression free survival. A prospective trial was conducted to determine the prevalence and severity of symptoms, and associated care needs. METHODS Eligible women included those with persistent or recurrent platinum-resistant ovarian cancer with an estimated life expectancy of at least 6 months. The Needs at the End-of-Life Screening Tool (NEST), FACIT-Fatigue (FACIT-F), NCCN-FACT Ovarian Symptom Index [NFOSI-18]; Disease Related Symptoms (DRS), Treatment Side Effects (TSE), and Function/Well Being (F/WB) were collected at study entry, 3 and 6 months. RESULTS We enrolled 102 evaluable patients. Initiation of Do Not Resuscitate (DNR) discussions increased over time from 28% at study entry to 37% at 6 months. At study entry, the most common disease-related symptoms were fatigue (92%), worry (89%), and trouble sleeping (76%); 73% reported being "bothered by treatment side effects", which included nausea (41%) and hair loss (51%) neither of which changed over time. The most common NEST unmet needs were in the symptom dimension. The social dimension was associated with F/WB (p = 0.002) and FACIT-F (p = 0.006); symptoms were associated with DRS (p = 0.04), TSE (p = 0.03), and FACIT-F (p = 0.04); existential was not associated with any of the patient-reported symptoms; therapeutic was associated with F/WB (p = 0.02). CONCLUSIONS In patients nearing the end of life, there are significant associations between disease and treatment related symptoms and unmet patient needs, which do not change substantially over time. Careful exploration of specific end-of-life care needs can improve patient-centered care and QOL.
Collapse
|
48
|
Dunbar SB, Khavjou OA, Bakas T, Hunt G, Kirch RA, Leib AR, Morrison RS, Poehler DC, Roger VL, Whitsel LP. Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association. Circulation 2018; 137:e558-e577. [DOI: 10.1161/cir.0000000000000570] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction:
In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.
Methods:
We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers’ wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant.
Results:
The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD.
Conclusions:
The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.
Collapse
|
49
|
Wang AY, Ma HP, Kao WF, Tsai SH, Chang CK. Characteristics and outcomes of "Do Not Resuscitate" patients admitted to the emergency department-Intensive care unit. J Formos Med Assoc 2018; 118:223-229. [PMID: 29731386 DOI: 10.1016/j.jfma.2018.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Appropriate utilization of intensive care unit (ICU) beds are essential. Patients with critical illness who have do not resuscitate (DNR) have a reduced priority of intensive care. However, the possibility of recovery/survival is ambiguous and multifactorial. OBJECTIVE To deliberate the characteristics and outcomes of critical illness in patients with prior DNR who were admitted to the emergency department (ED)-ICU. METHOD This was a retrospective cohort study conducted between April 2015 and November 2015 in a university-based hospital. Non-traumatic patients with DNR admitted to ED-ICU from ED were included. RESULTS Seventy-eight non-trauma patients with prior DNR status were included in the final analysis. 51.3% (40/78) patients were male with median age 83 (IQR: 75-89) years. The median APACHE II score was 24.5 (IQR: 20-30). 50% (39/78) of the DNR patients survived to discharge. Patients who survived to discharge had lower APACHE II score (23 (IQR: 20-28) vs. 28 (18-38), p = 0.028). There was no significant difference in age, gender, and Charlson index. ROC curves were constructed, generating a cut-off of the APACHE II score at 29.5 for determining survival to discharge (AUC = 0.644, p = 0.028). In multivariate Cox proportional model, APACHE II score above 29.5 was an independent predictor for mortality. (Hazard ratio = 2.46; 95% confidence interval: 1.04-5.83, p = 0.042). CONCLUSION Our study found that 50% of patients with prior DNR on ICU admission survived to discharge, indicating that aggressive care is not definitely futile. Further prospective studies are required to evaluate the cost-effectiveness and patients' and/or families' satisfaction of the ICU admission of DNR patients.
Collapse
Affiliation(s)
- An-Yi Wang
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Hon-Ping Ma
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Shuang Ho Hospital, New-Taipei City, Taiwan
| | - Wei-Fong Kao
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Shin-Han Tsai
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Shuang Ho Hospital, New-Taipei City, Taiwan
| | - Cheng-Kuei Chang
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, New-Taipei City, Taiwan.
| |
Collapse
|
50
|
Philip J, Remedios C, Breen S, Weiland T, Willenberg L, Boughey M, Jelinek G, Lane H, Marck C, Weil J. The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study. Palliat Med 2018; 32:439-446. [PMID: 29130378 DOI: 10.1177/0269216317735724] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients' perceptions of hospital Emergency Department presentations. AIM To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers. DESIGN Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame. SETTING/PARTICIPANTS In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed. RESULTS Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options. CONCLUSION Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.
Collapse
Affiliation(s)
- Jennifer Philip
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,2 Victorian Comprehensive Cancer Centre, Parkville, VIC, Australia.,3 Palliative Medicine, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | | | - Sibilah Breen
- 1 Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Tracey Weiland
- 5 Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Mark Boughey
- 3 Palliative Medicine, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - George Jelinek
- 5 Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Heather Lane
- 7 Rockingham General Hospital, Rockingham, WA, Australia
| | - Claudia Marck
- 5 Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer Weil
- 3 Palliative Medicine, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| |
Collapse
|