Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis

End-of-life emergency department use and healthcare expenditures among older adults: A nationally representative study

BACKGROUND

Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample.

METHODS

Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes.

RESULTS

Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001).

CONCLUSIONS

One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program

INTRODUCTION

80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice.

METHODS

We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS).

RESULTS

202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21).

CONCLUSION

In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.

Palliative care inpatients in Switzerland (2012-2021): characteristics, in-hospital mortality and avoidable admissions

OBJECTIVES

Palliative patients generally prefer to be cared for and die at home. Overly aggressive treatments place additional strain on already burdened patients and healthcare services, contributing to decreased quality of life and increased healthcare costs. This study characterises palliative inpatients, quantifies in-hospital mortality and potentially avoidable hospitalisations.

METHODS

We conducted a multicentre retrospective analysis using the national inpatient cohort. The extracted data encompassed all inpatients for palliative care spanning the years 2012-2021. The dataset comprised information on demographics, diagnoses, comorbidities, treatments and clinical outcomes. Content experts reviewed a list of treatments for which no hospitalisation was required.

RESULTS

120 396 hospitalisation records indicated palliative patients. Almost half were women (n=59 297, 49%). Most patients were ≥65 years old. 66% had an oncologic primary diagnosis. The majority were admitted from home (82 443; 69%). The patients stayed a median of 12 days (6-20). All treatments for 25 188 patients (21%) could have been performed at home. In-hospital deaths ended 64 739 stays (54%); of note, 10% (n=6357/64 739) of in-hospital deaths occurred within 24 hours.

CONCLUSIONS

In this nationwide study of palliative inpatients, two-thirds were 65 years old and older. Regarding the performed treatments alone, a fifth of these hospitalisations can be considered as avoidable. More than half of the patients died during their hospital stay, and 1 in 10 of those within 24 hours.

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

BACKGROUND

Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.

METHODS

Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.

RESULTS

Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001).

CONCLUSIONS

There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.

Implementation and evaluation of a palliative care training unit for EMS providers

Background

The prevalence of children with life-limiting conditions (LLCs) is rising. It is characteristic for these children to require 24/7 care. In emergencies, families must decide to call the emergency medical service (EMS) or a palliative care team (PCT)-if available. For EMS teams, an emergency in a child with an LLC is a rare event. Therefore, EMS providers asked for a training unit (TU) to improve their knowledge and skills in pediatric palliative care.

Aim of the study

The questions were as follows: whether a TU is feasible, whether its integration into the EMS training program was accepted, and whether an improvement of knowledge can be achieved.

Methods

We designed and implemented a brief TU based on findings of a previous study that included 1,005 EMS providers. The topics covered were: (1) basics in palliative home care, (2) theoretical aspects, and (3) practical aspects. After participating in the TU, the participants were given a questionnaire to re-evaluate their learning gains and self-confidence in dealing with emergencies in pediatric patients with LLC.

Results

782 (77.8%) of 1,005 participants of the previous study responded to the questionnaire. The average age was 34.9 years (±10.7 years SD), and 75.3% were male. The average work experience was 11.4 years (±9.5 years SD), and 15.2% were medical doctors. We found an increase in theoretical knowledge and enhanced self-confidence in dealing with emergencies in patients with LLC (confidence: before training: 3.3 ± 2.0 SD; after training: 5.7 ± 2.1 SD; min.: 1; max.: 10; p < 0.001). The participants changed their approaches to a fictitious case report from more invasive to less invasive treatment. Most participants wanted to communicate directly with PCTs and demanded a standard operating procedure (SOP) for treating patients with LLC. We discussed a proposal for an SOP with the participants.

Conclusion

EMS providers want to be prepared for emergencies in children with LLCs. A brief TU can improve their knowledge and confidence to handle these situations adequately. This TU is the first step to improve collaboration between PCTs and EMS teams.

Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician

Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.

Epidemiologic trends in cancer-related emergency department utilization in Korea from 2015 to 2019

It is inevitable for cancer patients to visit the emergency department (ED) for symptoms of cancer itself and various treatment-related complications. As the prevalence of cancer increases along with cancer survival rates, the number of ED visits of cancer patients may increase. This study aimed to investigate the epidemiologic trends and characteristics of cancer-related ED visits. A cross-sectional study was conducted for all ED visits nationwide between 2015 and 2019. The characteristics of cancer- and non-cancer-related ED visits were compared, and the cancer type and primary reason for ED visits were investigated for cancer-related ED visits. The age- and sex-standardized incidence rate per 100,000 population was calculated. Among 44,983,523 ED visits for 5 years, 1,372,119 (3.1%) were cancer-related. Among cancer-related ED visits, 54.8% led to hospitalization including 5.1% in ICU, and 9.5% died in the hospital. The age- and sex-standardized incidence rates of cancer-related ED visits per 100,000 population increased from 521.8 in 2015 to 642.2 in 2019 (p-for-trends, < 0.01), and rates of cancer-related hospital admission via ED were 309.0 in 2015 and 336.6 in 2019 (p-for-trends, 0.75). The most common cancer types were lung cancer (14.7%), liver cancer (13.1%), and colorectal cancer (11.5%). The most common primary reasons of cancer-related ED visits were pneumonia (3.6%), gastroenteritis (2.7%), fever (2.6%), abdominal pain (2.4%), and ileus (2.1%). Cancer-related ED visits accounted for 3.1% of all ED visits, with 1.37 million cases over five years. The incidence rate of cancer-related ED visits has increased year by year, with high hospitalization and mortality rates, and the burden of cancer-related ED visits will continue to increase as the prevalence increases.

Harnessing the Chaplain's Capacity to Identify Unmet Palliative Needs of Vulnerable Older Adults in the Emergency Department

OBJECTIVE

To explore chaplains' ability to identify unmet palliative care (PC) needs in older emergency department (ED) patients.

METHODS

A palliative chaplain-fellow conducted a retrospective chart review evaluating 580 ED patients, age ≥80 using the Palliative Care and Rapid Emergency Screening (P-CaRES) tool. An emergency medicine physician and chaplain-fellow screened 10% of these charts to provide a clinical assessment. One year post-study, charts were re-examined to identify which patients received PC consultation (PCC) or died, providing an objective metric for comparing predicted needs with services received.

RESULTS

Within one year of ED presentation, 31% of the patient sub-sample received PCC; 17% died. Forty percent of deceased patients did not receive PCC. Of this 40%, chaplain screening for P-CaRES eligibility correctly identified 75% of the deceased as needing PCC.

CONCLUSION

Establishing chaplain-led PC screenings as standard practice in the ED setting may improve end-of-life care for older patients.

Impact of Applying Palliative Care on Symptoms and Survival of Patients with Advanced Chronic Disease Admitted to the Emergency Department

Introduction:

In the emergency department, there is a need to provide palliative care; however, they are not usually administered. The present study evaluates the evolution of the intensity of the symptoms when applying palliative care, in adult patients with advanced chronic disease admitted to the emergency room, and compares survival between those who receive this care and those who do not.

Materials and Methods:

A clinical intervention study was conducted including patients older than 18 years with advanced chronic disease admitted to the emergency room with an indication of palliative support according to the Supportive and Palliative Care Indicators Tool 2015. Three hundred and seven patients were studied (74 in the intervention group and 233 in the group not intervened). In the intervention group, the intensity of pre- and postintervention symptoms was compared (Wilcoxon test). The survival of both the groups were then compared (logrank test).

Results:

There was a significant decrease in pain and dyspnea at 24 and 48 h postintervention (P < 0.01), respectively, while drowsiness increased significantly at 24 h (P < 0.01) but did not change at 48 h (P = 0.38). Excluding patients with better functional status, there was less survival at 3 months in the intervention group (P = 0.01).

Conclusions:

Dyspnea and pain decreased with the application of palliative care but not drowsiness. Survival in the intervention group was lower than in the nonintervention group. However, the reason for providing palliative care is to relieve suffering at the end of life.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

Caregiver perceptions of end-of-life care in patients with high-grade glioma

Background

Patients dying from high-grade gliomas (HGG) suffer from high symptom burden in the end-of-life (EoL) phase. Family caregivers are most informed about the patient's symptoms and disease course. The aim of this study is to assess caregiver perception on quality of EoL care of HGG patients.

Methods

Caregivers prospectively participated in the Toolkit After-Death Bereaved Family Member Interview, part of the Toolkit of Instruments to Measure End-of-Life Care (TIME survey). This validated survey assesses EoL care in areas such as physical comfort and emotional support, advance care planning, focus on the individual, attention to family, and coordination of care. The quality of EoL care was measured by domain scores (0 = care was always optimal, 1 = care was always suboptimal) or with a 0-10 scale.

Results

Of the 55 enrolled family caregivers, 44 completed the interview and rated the overall care high (8.90 ± 1.36/10), perceived that patients' wishes were respected (9.46 ± 0.95) and that they died in dignity (9.65 ± 0.98). Caregivers perceived high satisfaction with information and decision-making (0.18), advance care planning (0.19), focus on the individual (0.16), and care coordination (0.11). Attention to family (0.25) needed improvement. Only 41% of caregivers were confident that they knew what to do at the time of death and 46% felt that the healthcare team did not provide them with someone to turn to in distress.

Conclusions

Caregivers reported high overall satisfaction with EoL HGG care, though attention to family and communication needed improvement. Focus should therefore be on improved caregiver communication to improve EoL care, caregiver burnout, and bereavement in HGG populations.

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis

BACKGROUND

People who die from cancer (cancer decedents) may experience unpleasant and distressing symptoms which cause them to present to unscheduled care. Unscheduled care is unplanned care delivered by general practitioner out-of-hours and emergency departments. Use of unscheduled care can disrupt treatment plans, leading to a disjointed patient care and suboptimal outcomes.

OBJECTIVES

This systematic review aimed to identify factors associated with unscheduled care use by cancer decedents.

METHOD

Systematic review with narrative synthesis of seven electronic databases (PubMed; Medline; Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Web of Science; Cumulative Index to Nursing and Allied Health Literature) from inception until 01 January 2020. All observational and experimental studies were included, irrespective of their research design.

RESULTS

The search yielded 238 publications included at full-text, of which 47 were included in the final review and synthesis. Unscheduled care use by cancer decedents was influenced by multiple factors, synthesised into themes: demography, clinical and patient, temporal, prescribing and systems. Cancer decedents who were older, men, had comorbidities, or lung cancer, were most likely to use unscheduled care. Unscheduled care presentations were commonly due to pain, breathlessness and gastrointestinal symptoms. Low continuity of care, and oncology-led care were associated with greater unscheduled care use. Access to palliative care, having an up-to-date palliative care plan, and carer education were associated with less unscheduled care use.

CONCLUSION

The review identifies multiple factors associated with unscheduled care use by cancer decedents. Understanding these factors can inform future practice and policy developments, in order to appropriately target future interventions, optimise service delivery and improve the patient journey.

PROSPERO REGISTRATION NUMBER

CRD42016047231.

Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs

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.

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

CONTEXT

There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care.

OBJECTIVE

The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice.

METHODS

We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored.

RESULTS

We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs.

CONCLUSION

Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

A Systematic Approach to Comfort Care Transitions in the Emergency Department

BACKGROUND

Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress.

OBJECTIVES

To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient.

METHODS

Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients.

DISCUSSION

Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy.

CONCLUSION

Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.

Pain and Emergency Department Use in the Last Month of Life Among Older Adults With Dementia

CONTEXT

Pain may be a potentially modifiable risk factor for expensive and burdensome emergency department (ED) visits near the end of life for older adults with dementia.

OBJECTIVES

The objective of this study was to assess the effect of pain and unmet need for pain management on ED visits in the last month of life in older adults with dementia.

METHODS

This is a mortality follow-back study of older adults with dementia in the National Health and Aging Trends Study who died between 2012 and 2014, linked to Medicare claims.

RESULTS

Two hundred eighty-one National Health and Aging Trends Study decedents with dementia met criteria (mean age 86 years, 61% female, 81% white). Fifty-seven percent had at least one ED visit in the last month of life, and 46.5% had an ED visit that resulted in a hospital admission. Almost three out of four (73%) of decedents experienced pain in the last month of life, and 10% had an unmet need for pain management. After adjustment for age, gender, race, educational attainment, income, comorbidities, and impairment in activities of daily living, pain was not associated with increased ED use in the last month of life (adjusted incident rate ratio 0.87, 95% CI 0.64-1.17). However, decedents with unmet need for pain management had an almost 50% higher rate of ED visits in the last month of life than those without unmet needs (adjusted incident rate ratio 1.46, 95% CI 1.07-1.99).

CONCLUSION

Among older adults with dementia, unmet need for pain management was associated with more frequent ED visits in the last month of life.

Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system

BACKGROUND

Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems.

METHODS

This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used.

RESULTS

From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment.

CONCLUSIONS

Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.