Contraceptive Technology Update
Palliative care options can ease strain on EDs, improve care for patients with poor prognoses or difficult symptoms
New analysis questions use of the ED, inpatient admissions toward the end of life
In the intense focus of late on use of the ED by patients with non-emergent needs, it is perhaps easy to overlook another group of patients that is strongly linked with the ED: patients who are nearing the end of life. A new study suggests that for many of these mostly older patients, the ED visit triggers a hospital admission and a cascade of costly procedures that are nothing like what the patient would have chosen.
The study, which was published in Health Affairs, was based on an analysis of more than 4,500 health records of patients older than the age of 65 who died while participating in the Health and Retirement Study, a longitudinal study of older adults in the years between 1992 and 2006.1 The authors linked the Health and Retirement survey data to Medicare claims to ascertain ED utilization patterns. They found that half of these adults made at least one ED visit in the last month of their life, and that three-quarters of these visits resulted in hospital admissions. In addition, more than two-thirds of the patients who were admitted to the hospital died there. However, the authors note that the 10% of study participants who enrolled in hospice at least one month prior to their death were much less likely to visit the ED or to die in the hospital.
What's wrong with this picture? Study authors maintain that the ED's traditional focus on stabilization and triage is far from ideal for patients nearing the end of life, and that this type of trajectory only contributes to the high cost of care for both health care systems and the families. Further, they observe that it is not the kind of care that most of these patients and their families would prefer.
"If you were at the end-of-life stage, and you were not expected to live long, would you rather be sleeping in your own bed with the appropriate comfort measures, or would you rather be in a hospital ward with monitors beeping?" questions Jonathan Fisher, MD, MPH, a co-author of the study, and an assistant professor of emergency medicine at Tufts University, and vice chair of the Committee on Clinical Investigations at Beth Israel Deaconess Medical Center in Boston, MA. "I think there is going to be more discussion about this in the future as we try to figure out how to keep patients out of hospitals."
Fisher acknowledges that a discussion about end-of-life care should ideally occur before a patient reaches the final stages of a terminal illness. Then both the patient and his or her primary care providers will have a care plan in place, and it won't come as a surprise to the patient. However, such discussions are often delayed until a patient ends up in the ED with some type of acute exacerbation of their disease. "Someone may come in with a devastating illness, such as an intracranial hemorrhage, for example, that is clearly not going to result in a good outcome for the patient," he says. "If a return of function and survival is not predicted to be good, then I think you need to have a discussion at that time about what the goal of care should be."
Unfortunately, transitioning the patient to a hospice setting or arranging for palliative care services is difficult if the ED does not already have relationships established with these types of community resources. "The education piece is the easy part. I think most ED providers have a fairly good sense of what patients would be good candidates for this type of care," says Fisher. "It is delivering on the resources that is the hard part."
Help patients make informed decisions
There are clear advantages available to EDs that have palliative care resources at close hand. For example, Virginia Commonwealth University Medical Center (VCUMC) in Richmond, VA, has had a dedicated palliative care unit on the VCCUMC campus since May of 2000, and it has always worked closely with the ED, explains Laurie Lyckholm, MD, director of the VCU School of Medicine's Hospice and Palliative Medicine fellowship program.
"The ED is a priority with us because we know that the sooner we can get to the patients who may need a palliative care consultation, the better the outcome will be," explains Lyckholm. "Instead of having patients wait for one of those very precious ICU beds, we may be able to get them either into our 11-bed unit or into the hospital with a palliative care consult, with the idea of eventually bringing them to our unit. That improves ED throughput, which is a really critical problem right now."
The physicians and nurses in the ED don't have a specific trigger for when to call for a palliative care consultation, but they have a "pretty high index of suspicion" when patients have a high degree of debility, or they are in the late stages of a disease, explains Lyckholm. However, she explains that patients don't necessarily have to have a poor prognosis to benefit from palliative care; they could be experiencing very difficult symptoms such as a high degree of pain.
For example, a teenage patient with sickle cell disease who may have years to live but is in terrible pain, or an early-stage breast cancer patient who is having extreme difficulty with nausea from chemotherapy, could both benefit from palliative care consultations, offers Lyckholm.
"The ED will call us about symptom management whenever they think someone is experiencing symptoms that are beyond the realm of a general physician treating them successfully," explains Lyckholm, "or they will call when somebody has a poor prognosis and is presenting with an acute or chronic illness that they think might be better served with palliative care than an acute inpatient admission or admission to the ICU."
In fact, the palliative care process is so well ingrained at VCUMC at this point that little, if any, time is lost when a patient who presents to the ED for care requires a palliative care consultation. "Sometimes we will see the patient at the same time ICU staff are meeting with the patient," explains Lyckholm. "We will discuss what the goals of care are, and whether there is any chance this patient is going to get much better."
During this discussion, patients and/or their families can make an informed decision about whether to opt for aggressive treatment in the ICU or palliative care, where their symptoms will be managed, and they can possibly be discharged that same day with hospice, avoiding an inpatient hospital admission, explains Lyckholm.
"The physicians and nurses in the ED are critical to getting us down there," stresses Lyckholm. "We try to be very open to them even when they are calling us about a patient who we think is probably not a good candidate for palliative care. We will go down there no matter what because we want to keep the lines of communication open. The more that we see these patients, the better the outcomes."
Understand the financial impact
It is not unusual to encounter patients in the ED who have no real understanding that they are in the final stages of a terminal disease, observes Lyckholm. "We may see a patient with late-stage cancer who has nausea and pain, and no one has talked with them yet about what their real prognosis is yet," she says. "Sometimes what is required is lots of calls [to the patient's other providers] and lots of discussion, which is another reason why the ED physicians appreciate having us come down because we can take more time to have the goals-of-care discussion, where we talk about what the patient's preferences are and what they understand about their disease."
There are definitely patients in these circumstances who opt for aggressive treatment, and that is their prerogative, explains Lyckholm. "We want them to make a really good, informed decisionand to know that we can make them comfortable, and allow them to have some really good time without terrible suffering, and without being in the hospital."
The strong palliative care presence at VCUMC has produced educational benefits in the sense that all hospital clinicians are now more knowledgeable about palliative care and skilled at discussing it with their patients, notes Lyckholm. "When we first started [the palliative care program] some of our very best customers were the neurosurgeons. They would have patients who came in with very severe head injuries, and they would do everything possible, but they would get to a point where there wasn't anything else that could be done, and then they would call us," she says. "They became very used to having family meetings, having discussions about goals of care, and transferring patients to us, so there is a lot of informal [education] that is happening, and it is very exciting."
Further, while cost has never been the reasoning behind VCUMC's palliative care program, there is no question that the cost of care goes down when patients avoid going to the ICU or avoid hospital admissions. "We have some pretty significant cost-of-care data that shows much improved cost margins," adds Lyckholm. However, she stresses that offering palliative care options is not about the money. "It is important to know about [the financial impact] because there are really good administrative points to make when you want more funding and more people on your [palliative care] team, but we are not doing this for cost savings."
Lobby for a palliative care consult team
While dedicated palliative care units are not very common in the hospital setting, there are still good palliative care options available to EDs. Lyckholm recommends that ED leaders lobby for the creation of palliative care consult teams who can respond to cases anywhere in the hospital, including the ED. "There are palliative care teams in many hospitals now. They may consist of a nurse practitioner and a social worker, and there may be a physician hospitalist who champions the approach," she says. "We conduct about 1500 consults a year, and we go everywhere, from the ED to outpatient departments to the dialysis unit and the psych units."
Further, even in hospitals that don't have formal palliative care options, physicians and nurses can be educated about how to identify patients who might be good candidates for palliative care, and how to have goals-of-care discussions. "Learning those skills goes a long way," stresses Lyckholm.
Emergency department administrators can find a wealth of information, tools, and resources at Improving Palliative Care in the Emergency Medicine, an online portal that has been set up with the support of the Center to Advance Palliative Care and the Olive Branch Foundation: www.capc.org/ipal/ipal-em.
- Smith A, McCarthy E, Weber E, et al. Half of older adults seen in emergency department in last month of life: Most admitted to hospital and many die there. Health Affairs 2012; 31:1277-1285.
- Jonathan Fisher, MD, MPH, Assistant Professor, Emergency Medicine, Tufts University, and Vice Chair, Committee on Clinical Investigations, Beth Israel Deaconess Medical Center, Boston, MA. E-mail: [email protected].
- Laurie Lyckholm, MD, Director, Hospice and Palliative Medicine Fellowship Program, Virginia Commonwealth University School of Medicine, Richmond, VA. E-mail: [email protected].
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