Emergency Department Referral for Hospice and Palliative Care Differs among Patients with Different End-of-Life Trajectories: A Retrospective Cohort Study

A Hospice Transitions Program for Patients in the Emergency Department

Importance

Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care.

Objective

To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life.

Design, Setting, and Participants

This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022.

Main Outcome and Measures

The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality.

Results

This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001).

Conclusions and Relevance

In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Qualitative study on the perception of good death in patients with end-stage cancer in oncology nurses

OBJECTIVE

To explore the perception of good death of patients with end-stage cancer by nurses in the oncology department.

METHOD

In the study we used a phenomenological approach and semi-structured interviews. A total of 11 nurses from the oncology department of a Grade A hospital in Taizhou were interviewed on the cognition of good death from July 1 to September 30, 2022. Colaizzi's analysis method was used to analyse the interview data. This study followed the consolidated criteria for reporting qualitative research (COREQ).

RESULT

Four themes were identified: a strong sense of responsibility and mission; To sustain hope and faith; The important role of family members; Improve patients' quality of life.

CONCLUSION

The nurses in the department of oncology have a low level of knowledge about the "good death", and the correct understanding and view of the "good death" is the premise of the realization of " good death". The ability of nursing staff to improve the "good death", attention, and meet the needs and wishes of individuals and families, is the guarantee of the realization of "good death".

Quality of referrals to specialist palliative care and remote patient triage - a cross-sectional study

PURPOSE

Choosing the optimal moment for admission to palliative care remains a serious challenge, as it requires a systematic identification of persons with supportive care needs. Despite the screening tools available for referring physicians, revealing the essential information for preliminary admission triage is crucial for an undisturbed qualification process. The study was aimed at analysing the eligibility criteria for specialist palliative care disclosed within provided referrals, expanded when necessary by documentation and/or interview.

METHODS

Referral forms with the documentation of 300 patients consecutively referred to the non-profit in-patient ward and home-care team in Poland were analysed in light of prognosis, phase of the disease and supportive needs.

RESULTS

Half of the referrals had the sufficient information to make a justified preliminary qualification based solely on the delivered documentation. The majority lacked performance status or expected prognosis. Where some information was revealed, two-thirds were in a progressing phase of the disease, with a within-weeks life prognosis. In 53.7%, no particular reason for admission was given. Social problems were signalled as the only reason for the admission in 7.7%. Twenty-eight percent were labelled as "urgent"; however, 52.4% of them were triaged as "stable" or disqualified. Patients referred to a hospice ward received complete referral forms more often, containing all necessary information.

CONCLUSIONS

General physicians need practical tips to facilitate timely referrals and unburden the overloaded specialist palliative care. Dedicated referral forms extended by a checklist of typical patients' concerns should be disseminated for better use of these resources.

Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review

BACKGROUND

Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research.

METHODS

We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods.

RESULTS

A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission.

CONCLUSION

The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed.

REGISTRATION

https://doi.org/10.17605/OSF.IO/W2F8N.

Hospice Care Preferences and Its Associated Factors among Community-Dwelling Residents in China

Hospice care is a comprehensive approach addressing patients’ physical, psychosocial, and spiritual needs at the end of life (EoL). Despite the recognition of its effectiveness in improving the quality of EoL care, little is known about hospice care in mainland China. In this study, we aimed to examine the preferences for hospice care and its related factors among community-dwelling residents in mainland China. Participants were recruited using a convenience sampling method, and 992 community-dwelling residents responded to an online survey from June 2018 to August 2019. The majority (66.7%) of the participants were female, and the mean age was 48.4 years. Approximately 28% of the participants had heard of hospice care, and 91.2% preferred to receive hospice care if diagnosed with a terminal illness. Participants who had heard of hospice care, and with higher levels of education (bachelor’s degree or above) and health insurance coverage were more likely to accept hospice care than their counterparts. Community-based education on hospice care is imperative to improve public knowledge and the acceptance of hospice care. Meanwhile, there is a need to develop policies to integrate and expand hospice care into clinical settings.