Palliative Care, Part 1

The Importance of Early Implementation in the ED

Emily is tired. The illness is evident when she arrives in the emergency department (ED). You can see it in her face, her skin, her eyes. What little hair she has left is pulled back, and her face is haggard beyond its years. Her condition has not responded to treatment, and she is beginning to grow accustomed to the lack of energy. She does not grow accustomed to the pain, however — pain that increases steadily and has driven her to initiate difficult conversations with her family. With the inevitable drawing closer, her loved ones seek ways to mitigate Emily's pain and ease her suffering.

While Emily functions here only as a symbol, her story represents the stories of many patients. For these patients, the ED serves as the gateway to alleviation and amelioration of symptoms often too insurmountable or scary for them to face alone.

Early initiation and consistent provision of palliative care within hectic, overburdened, and resource-limited EDs can be challenging. Providers admittedly face several logistical barriers, including knowledge deficits, time constraints, and infrequent advance care planning in older or terminally ill adults.¹ However, data have demonstrated that the provision of palliative care in the ED may not only be beneficial for patients like the fictional Emily, but also may be advantageous for departments and medical providers.

Data correlates palliative care integration in the ED with reductions in medical overtreatment, reductions in health care costs, and increased quality of life for patients with advanced illnesses; thus ACEP and the Agency for Healthcare Research and Quality alike have begun advocating for the incorporation of palliative care in the ED.² Likewise, the Choosing Wisely Campaign has encouraged providers to initiate palliative and hospice care services early for patients who are likely to benefit.³ Through this series, the authors intend to demonstrate that, while seemingly challenging, the integration of palliative care into one's emergency medicine practice is beneficial and practical for providers and patients.

Why Should We Care?

Although some may argue that palliative care interventions should be implemented as part of inpatient treatment only, literature supports that end-of-life care is both important and germane to medical practice in the ED. Up to 81% of individuals aged 65 or older visit the ED during the last 6 months of their lives. Among these, the majority are eventually admitted to and die in the hospital.^4,5 Data also show that many of these visits could be avoided. One study found that approximately a quarter of ED visits made by patients receiving some form of care for advanced cancer were potentially avoidable. Another study found these visits were primarily due to uncontrolled symptoms, further supporting the role emergency physicians play in symptom management and quality of life measures within these patient populations.^6,7

Conversely, the literature has shown that individuals consistently enrolled in hospice or palliative care services rarely visit the ED overall and are much less likely to visit within the last month of life. Reviewing Medicare-claim-linked data to identify characteristics contributing to ED use at the end of life, Smith et al. found that early hospice usage was a commonality among individuals who did not present to the ED in the last month of life^.4 A subsequently performed international systematic review came to the same conclusion.⁸ This data not only highlights a need and opportunity for providers to intervene on behalf of their patients and departments, but could also prompt one to consider why, over time, the provision of costly and often futile advanced medical management continues to seemingly outweigh our utilization of advantageous palliative care management options.

Why (Else) Should We Care?

Hospital-wide, an inpatient course is directed by ED-derived diagnoses and treatment initiation; end-of-life care is no exception. Early implementation of palliative care into the ED cuts back on intensive care and standard admission rates, treatment costs, and length of stay.

A systematic review of palliative care interventions in intensive care units found that the relative risk of admission and longer length of stay was significantly reduced in those who received palliative care services.⁹ One study performed within the ED found that, despite meeting criteria for admission to critical care or step-down units, more than half of all admitted patients who received palliative care interventions were instead admitted to medical or surgical units. Upon analyzing those who received this intervention and were subsequently discharged from the ED, more than half met admission criteria, and a staggering 50% would have met criteria for critical care admission.¹⁰

Moreover, on review of these findings, one can attempt to further extrapolate the potential resource and cost-saving implications of ED-initiated palliative care. Upon examination of end-of-life care within the intensive care unit, one study found that approximately a quarter of health care costs are spent at the end of life.¹¹ Furthermore, a review of end of life costs found that through use of hospice and implementation of advance directives, expenditures can be reduced from 25 to 40 percent.¹² Advance directives were associated with decreased Medicare expenditures and lower rates of in-hospital death, particularly in higher-spending regions.¹³

These findings not only emphasize the magnitude of potential cost saving through palliative care service enrollment and advance directive creation, they also accentuate concurrent benefits for both patients and providers, particularly with respect to the avoidance of unnecessary and intervention-laden admissions.

Now What?

Although providers may be unable to alleviate the afflictions of patients such as our fictional Emily, they do have the power to ameliorate a portion of their emotional, financial, and symptomatic burdens. Through the timely implementation of palliative care in the ED, practitioners can not only promote enhanced quality of care but can foster better departmental and institutional resource utilization while doing so. How can one begin to do this within the highly taxing and hectic ED environment? Stay tuned for the second installment of our series.

References

1. Grudzen C, Richardson LD, Baumlin KM, et al. Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units. Health Aff. 2015;34(5):788-795.
2. Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med. 2011;18(6):e70-e76.
3. American College of Emergency Physicians. Five Things Physicians and Patients Should Question. Irving, TX: American College of Emergency Physicians; 2014. http://www.choosingwisely.org/societies/american-college-of-emergency-physicians/. Accessed May 5, 2016.
4. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). 2012;31(6):1277-1285.
5. Obermeyer Z, Clarke AC, Makar M, Schuur JD, Cutler DM. Emergency care use and the Medicare hospice benefit for individuals with cancer with a poor prognosis. J Am Geriatr Soc. 2016;64(2):323-329.
6. Delgado-Guay MO, Kim YJ, Shin SH, et al. Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care. J Pain Symptom Manage. 2015;49(3):497-504.
7. Alsirafy SA, Raheem AA, Al-Zahrani AS, et al. Emergency department visits at the end of life of patients with terminal cancer: pattern, causes, and avoidability. Am J Hosp Palliat Care. 2015;33(7):658-662.
8. Henson LA, Gao W, Higginson IJ, et al. Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. J Clin Oncol. 2015;33(4):370-376.
9. Khandelwal N, Kross EK, Engelberg RA, Coe NB, Long AC, Curtis JR. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med. 2015;43(5):1102-1111.
10. Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med. 2013;14(6):633-636.
11. Curtis JR, Engelberg RA, Bensink ME, Ramsey SD. End-of-life care in the intensive care unit: can we simultaneously increase quality and reduce costs? Am J Respir Crit Care Med. 2012;186(7):587-592.
12. Emanuel EJ. Cost savings at the end of life. What do the data show? JAMA. 1996;275(24):1907-1914.
13. Nicholas LH, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306(13):1447-1453.