No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Palliative Care in the Emergency Department
Abstract
Patients seek care in the emergency department (ED) for immediate relief of pain or other symptoms. Emergency physicians are trained to provide care that focuses on disease-directed treatment of acute illnesses; the ED is not considered an entry point for palliative care. Despite this, many patients with chronic or end-stage diseases seek treatment in the ED each year. Improving quality of life (QOL) is an overarching principle of palliative care. The ED is poised to improve patients' QOL by providing palliative interventions to manage pain and exacerbations of chronic illnesses or care near the end of life.
Published by Elsevier Inc.
... The integration of EOLC into emergency work has gained significant momentum over the past decade [1,4]. It is now necessary that emergency doctors and nurses possess the skills to deliver EOLC as part of their role and responsibilities [4]. ...
... The integration of EOLC into emergency work has gained significant momentum over the past decade [1,4]. It is now necessary that emergency doctors and nurses possess the skills to deliver EOLC as part of their role and responsibilities [4]. In contrast, the education of emergency doctors and nurses aims to equip them with the knowledge and skills to prevent deaths and provide lifesaving interventions, for example resuscitative interventions, treatment modalities, and technology to prolong life [5,6]. ...
... A (team) of researcher(s) analysed selected transcribed interviews or texts. 4 Any disagreements on interpretation were resolved by going back to the text. 5 Common meanings and shared practices were identified by comparing and contrasting text. ...
Background
End of life care in the emergency department is environmentally and culturally challenging. The aim of this study was to determine Australian emergency department doctors and nurses’ perceptions of their roles in providing end of life care in this environment.
Methods
Perceptions of end-of-life care roles were identified through semi-structured interviews with doctors and nurses using Dieklemann’s seven interpretative stages of analysis guided by phenomenological interpretive underpinnings (hermeneutics). Nine nurses and seven doctors were recruited using purposive sampling. Organisations for emergency doctors (Australasian College for Emergency Medicine: ACEM) and emergency nurses (College of Emergency Nursing Australasia: CENA) were approached to advertise the study and recruit participants across Australia via email.
Results
Results were categorised into four themes namely: role perception; the intensive nature of the role; emotional burden; and role integration. The participants stated that end of life care was provided according to their professional roles and responsibilities. Doctors and nurses had distinct tasks, some of which overlapped. The accounts of the participants in relation to their understanding of each other’s roles highlighted differences in how nurses perceived the role of doctors, and vice versa. The participants spoke about aspects that had an impact on their role of practicing end of life care in the emergency department setting.
Conclusions
In this study, all participants expressed concern for dying patients in the emergency department. The delivery of quality end of life care was believed to be paramount and required staff to work together to achieve the best outcome for the dying patient and their families. Regardless of the similarities and differences that were perceived within their roles, the nurses and doctors believed that their main objective was to ensure that comfort care was provided to dying patients.
... Clinical factors inability to recognize imminent death [16], lack of good-quality palliative care [17] or the overburden of the caregiver [18], can lead to the terminally-ill patient being admitted to the ED. As the access gate to in-hospital care, the ED is not designed for providing palliative care or looking after a dying http person [19,20]. A dying person's dignity implies treating him/her as an end in itself [21], recognizing his/her value as a person, as well as his/her self-esteem and autonomy [22]. ...
... However, influenced by fragmented care, the overburden of the informal caregiver [18] and other clinical, demographic and environmental factors [16], many patients in the terminal phase, often due to acute exacerbation of symptoms, seek care in these departments. In contrast to our participants, some authors note that EDs can improve the quality of life of dying patients, delivering palliative interventions to control the pain and exacerbation of chronic conditions in end-of-life care [20]. The dignity of end-oflife care in the ED can be hindered by architectural and organizational characteristics, healthcare professionals' attitudes and family members' decisions. ...
Background:
Preservation of a dying person's dignity in the emergency department (ED) is fundamental for the patient, his/her relatives and healthcare professionals. The aim of this study was to explore and interpret physicians' and nurses' experiences regarding conservation of dignity in end-of-life care in dying patients in the ED.
Methods:
A qualitative study based on the hermeneutic phenomenological approach, was carried out in the emergency department of two general hospitals. A total of 16 nurses and 10 physicians participated in the study. Data collection included 12 individual in-depth interviews and 2 focus groups.
Results:
The findings revealed that two themes represent the practices and proposals for the conservation of dignity in the emergency department: dignified care in hostile surroundings and the design of a system focused on the person's dignity.
Conclusion:
Dignifying treatment, redesigning environmental conditions, and reorienting the healthcare system can contribute to maintaining dignity in end-of-life care in the ED.
... 12 At the same time, there is tension between the hope of life offered by hospital treatment and the sense of loneliness offered by hospital-based palliative care. 13 In addition, most palliative care facilities in China lack 1 School of Aging Services and Management, Nanjing University of Chinese Medicine, Nanjing, China relatively independent wards and psychosocial care, 14 and the loss of other patients around them can cause further psychological distress. 15 The balance between the expectations of family members and the patient's own disease progression has not yet fully materialized, and there is a need to increase the amount of psychosocial care and medical support needed by patients and families. ...
Objectives: This study examined people's preference for the location to receive palliative care services and determined the associated factors. Methods: A questionnaire with reference to the Chinese version of the Hospice Attitude Scale and the Death Correspondence Scale was designed, piloted, revised, and distributed online and in person to collect data (N = 762). Binary logistic regression was used to analyze the effects of relevant factors. Results: The average age of the participants was 38.1, with a relatively even gender distribution. Over 90% of the participants were either single/never married (44.9%) or married with children (46.0%). 58.1% of the respondents (N = 428) indicated that they would like to receive palliative care at home, compared to 41.9% who preferred receiving such care in institutions or other places (N = 309). Each time people's attitudes toward death became one point more positive, they were 10.2% more likely to choose to receive palliative care services at home. People with a neutral attitude toward palliative care, single/never married or divorced with children, and having/had an occupation in health and social work had higher odds of preferring receiving palliative care at home. Those who had poor self-rated health or with an educational background of primary school or lower or some college had lower odds of preferring receiving palliative care at home. Conclusions: The research showed that attitudes toward death and other factors were associated with people's preferences for palliative care locations. More accessible and affordable community-based and home-based palliative care services should be further explored and provided.
... Rojas et al. [35] reported the effectiveness of a particular protocol based on an increase in the number of letters received from families; other measures of effectiveness were not reported. The included reviews (Bell, 2018 [29], Lamba, 2010 [33], Long, 2020 [34], Solberg, 2015 [37], Siegel, 2017 [36]) were heterogeneous in terms of proposed medications and overall approach. Bell et al., 2018 [29], discussed the need for ED clinicians to recognise the need for palliative care, communicate effectively and manage symptoms in actively dying patients. ...
Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.
... The skills and time needed for holistic end-of-life care compete with the priorities of managing acute emergencies [1,2]. However, the ED frequently becomes the dying patient's gateway to such care [3] when they have unmanageable symptoms, financial issues, or limited access to community resources [4]. ...
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
... Those who lack a dental home may visit hospital EDs to address their dental pain and related conditions. Hospitals typically respond to ED visits with palliative care and do not address the root cause of the pain [12]. Sociodemographic factors such as poverty, race, ethnicity, unemployment and educational attainment have an impact on the rate of dental utilization in young adults [13]. ...
Objective
To ascertain the financial impact associated with the underutilization of preventive dental care for adults enrolled in Medicaid.
Methods
We used adult claims data for patients aged 21–64 in the IBM Watson Marketscan Medicaid database. Enrollees were included if they had at least one dental claim in 2019 and were continuously enrolled between 2014 and 2019. We then evaluated the costs of their dental care in 2019, based on the number of years of preventive dental care they received between 2014 and 2018. We also assessed Emergency Department (ED) utilization for dental conditions, oral surgeries, and dental-related opioid prescriptions.
Results
The average Medicaid enrollee with five continuous years of preventive care prior to 2019 experienced 43% lower costs than an individual who received no preventive dental care at all. Most of the savings were a result of fewer oral surgeries. A Medicaid enrollee with no preventive dental visits was eight times more likely to have an ED visit for a nontraumatic dental condition (NTDC), seven times more likely to have oral surgery and six times more likely to receive a dental-related opioid prescription compared to those who had a dental prevention visit every year in the 5-year lookback period.
Conclusions
Regular preventive dental care in the lookback period was associated with significant savings in overall dental care costs when compared to dental care costs for those individuals who received no or few preventive visits. Prior preventive dental care was also associated with lower rates of ED-NTDC utilization, oral surgery, and dental-related opioid prescriptions.
... A palliative care team, including specialist doctors, nurses, social workers, nutritionists and chaplains, gives caregivers indispensable medical and emotional assistance so that they can smooth the transition of palliative care from the hospital to home [4]. Otherwise, patients often seek urgent medical services for the emergency department (ED) [5]. ...
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.
Objective
Dyspnea symptom is a common trigger of emergency department among the terminal illness and cancer patients. The frequent emergency department (ED) visits at the end of life are the indicator of poor-quality care. We examine the emergency department visits rate due to dyspnea symptom among the palliative patients by enhanced home palliative care.
Methods
In our home palliative care team, patients are managed by palliative care specialists, residents, home care nurses, social workers, and chaplains. We enhanced the weekly home palliative care visit time from 5 days a week to 7 days a week, one to two times visit per week based on patient’s need, to devise team-based medical services and formulate standard operating procedures for dyspnea care.
Results
Our team cared for a total of 762 patients with 512 ED visits, and 178 ED visits because of dyspnea (mean ± SD age, 70.4 ± 13.0 years; 49.4% male). Dyspnea (27.8%) was the most common reason recorded for ED visit, followed by pain (19.0%), GI symptoms (15.7%), and fever (15.3%). The analysis of unexposed versus exposed groups revealed that the proportion of non-family workers (42.9% vs.19.4%) and family members (57.1% vs. 80.6%) acting as caregivers significantly changed than basic (P <0.05). Compared with ED visits of unexposed group, the risks evidently decreased 30.7% in exposed group (P <0.05).
Conclusion
This study proves that comprehensive home palliative care with add two days per week and formulate standard operating procedures for dyspnea could significantly reduce ED visits rate because of controllable dyspnea in the last six months of life.
Consultations of palliative care (PC) patients (oncological and non-oncological) to the Emergency Department (ED) occur with a certain frequency, especially when approaching the end of life. The approach of palliative medicine (based on the patient and its quality of life) and the approach of emergency medicine (disease-based) are inapparent divergence; and there are still no established norms on the role of PC in the ED. On the other hand, education in PC to medical students, residents, specialists and general health personnel is scarce. This review discusses the importance of PC in ED, their integration, the approach, the barriers of attention, the benefits and the value of adding PC to academic training.
Consultation-liaison psychiatry (CLP) is a psychiatric subspecialty addressing the psychological care of medically ill patients as well as the relationship between medical and psychiatric disorders. As a specialty, it has developed over the last 30 years. Yet several cultural and organizational problems in different countries have emerged, including differences regarding implementing CLP services and in the application of CLP guidelines. This paper examines the progress and challenges of CLP in three culturally diverse countries: the UK, Italy, and Japan. In all three countries, the provision of CLP service remains insufficient, and the application of officially acknowledged standards of care is necessary.
Delirium is a complex but common disorder in palliative care with a prevalence between 13 and 88 % but a particular frequency at the end of life (terminal delirium). By reviewing the most relevant studies (MEDLINE, EMBASE, PsycLit, PsycInfo, Cochrane Library), a correct assessment to make the diagnosis (e.g., DSM-5, delirium assessment tools), the identification of the possible etiological factors, and the application of multicomponent and integrated interventions were reported as the correct steps to effectively manage delirium in palliative care. In terms of medications, both conventional (e.g., haloperidol) and atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine, aripiprazole) were shown to be equally effective in the treatment of delirium. No recommendation was possible in palliative care regarding the use of other drugs (e.g., α-2 receptors agonists, psychostimulants, cholinesterase inhibitors, melatonergic drugs). Non-pharmacological interventions (e.g., behavioral and educational) were also shown to be important in the management of delirium. More research is necessary to clarify how to more thoroughly manage delirium in palliative care.
Background:
Delirium is a common underdiagnosed condition in advanced cancer leading to increased distress, morbidity, and mortality. Screening improves detection but there is no consensus as to the best screening tool to use with patients with advanced cancer.
Objective:
To determine the incidence of delirium in patients with advanced cancer within 72 hours of admission to an acute inpatient hospice using clinical judgement and validated screening tools.
Method:
One hundred consecutive patients with advanced cancer were invited to be screened for delirium within 72 hours of admission to an acute inpatient hospice unit. Two validated tools were used, the Delirium Rating Scale-Revised 98 (DRS-R-98) and the Confusion Assessment METHOD (CAM) shortened diagnostic algorithm. These results were compared with clinical assessment by review of medical charts.
Results:
Of 100 consecutive admissions 51 participated and of these 22 (43.1%) screened positive for delirium with CAM and/or DRS-R-98 compared to 15 (29.4%) by clinical assessment. Eleven (21.6%) were identified as hypoactive delirium and 5 (9.8%) as subsyndromal delirium.
Conclusion:
This study confirms that delirium is a common condition in patients with advanced cancer. While there remains a lack of consensus regarding the choice of delirium screening tool this study supports the CAM as being appropriate. Further research may determine the optimal screening tool for delirium enabling the development of best practice clinical guidelines for routine medical practice.
Psychopharmacological intervention is a major clinical and research area in oncology and palliative care. Over the last 35 years, psychotropic drugs have been shown to have a number of important indications for the treatment of the most common psychiatric disorders, such as depression, anxiety, stress-related syndromes, severe adjustment disorders, sleep disorders and delirium, which combined affect at least 30-40% of patients with cancer and even a higher percentage of patients in an advanced phase of illness. The availability of new drugs, with less side-effects and safer pharmacological profiles, has been a major advance in clinical psycho-oncology. Interestingly, several drugs have also been found to be helpful for the adjuvant treatment of cancer-related symptoms, such as pain, hot flashes, pruritus, nausea and vomiting, fatigue, and cognitive impairment, making psychopharmacology an important tool for the improvement of cancer patients' quality of life. The aim of this paper is to summarize recent relevant data concerning the use of psychotropic drugs, namely antidepressants, anxiolytics, antipsychotics, anticonvulsants and psychostimulants in patients with cancer.
In most developed countries, acute hospitals play a significant role in palliative care provision and are the setting in which most people die. They are often the setting where a life-limiting diagnosis is made and where patients present when symptoms develop or when they are not well managed. Understanding the experiences of hospital admissions for people with a life-limiting illness and their families is essential in understanding the role acute hospitals play in providing palliative care.
Aim: The aim of this review is to synthesise current evidence regarding the experience of palliative care in an acute hospital setting from the perspectives of patient and family.
Design: An integrative review was completed using standard processes followed by a process of data extraction and synthesis.
Data sources: Using predefined search terms, literature was sourced from five electronic databases including MEDLINE (EBSCO), CINAHL, EMBASE, Cochrane and PsycINFO between January 1990 and November 2011. Reference lists from relevant articles were cross-checked and pertinent journals hand searched for articles.
Results: In total, 32 articles were included in the review. Five recurring themes were identified from the synthesised data: symptom control and burden, communication with health professionals, decision-making related to patient care and management, inadequate hospital environment and interpersonal relationships with health professionals.
Conclusion: This review has identified that, largely as a result of study design, our knowledge of patient and family experiences of palliative care in an acute hospital remains limited to discrete aspects of care. Further research is required to explore the total patient and family experience taking into account all aspects of care including the potential benefits of hospital admissions in the last year of life.
Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging).
Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition.
Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.
Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.
We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.
Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).
NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.
For patients dying of cancer, a visit to the emergency department can be disruptive, distressing and exhausting. Such visits made near the end of life are considered an indicator of poor-quality cancer care. We describe the most common reasons for visits made to the emergency department during the final six months of life and the final two weeks of life by patients dying of cancer.
We performed a descriptive, retrospective cohort study using linked administrative sources of health care data.
Between 2002 and 2005 in Ontario, 91,561 patients died of cancer. Of these, 76,759 patients made 194,017 visits to the emergency department during the final six months of life. Further, 31,076 patients made 36,600 visits to the emergency department during the final two weeks of life. In both periods, the most common reasons were abdominal pain, lung cancer, dyspnea, pneumonia, malaise and fatigue, and pleural effusion.
Many visits made to the emergency department by patients with cancer near the end of life may be avoidable. An understanding of the reasons for such visits could be useful in the development of dedicated interventions for preventing or avoiding their occurrence.
Delirium occurs in approximately 1 in 5 general hospital admissions and up to 85% of patients with terminal illness, but can be difficult to differentiation from other disorders, such as depression.
The authors assessed and compared mood states as they relate to onset of delirium.
Symptoms of depression and delirium were assessed in 100 consecutive palliative-care admissions immediately after admission and 1 week later.
Overall, 51% experienced either major depression or delirium. Most patients with syndromal delirium also met criteria for major depressive illness, and 50% of those with depression had delirium or subsyndromal delirium (SSD). Delirium symptoms were less common in patients with major depression than depressive symptoms in patients with delirium or SSD.
Delirium should be considered in patients with altered mood states, and screening for depression should initially rule out delirium. Sustained alterations in mood may be more frequent in delirium than previously recognized.
Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.
Hospital palliative care consultation teams have been shown to improve care for adults with serious illness. This study examined the effect of palliative care teams on hospital costs.
We analyzed administrative data from 8 hospitals with established palliative care programs for the years 2002 through 2004. Patients receiving palliative care were matched by propensity score to patients receiving usual care. Generalized linear models were estimated for costs per admission and per hospital day.
Of the 2966 palliative care patients who were discharged alive, 2630 palliative care patients (89%) were matched to 18,427 usual care patients, and of the 2388 palliative care patients who died, 2278 (95%) were matched to 2124 usual care patients. The palliative care patients who were discharged alive had an adjusted net savings of 279 in direct costs per day (P < .001) including significant reductions in laboratory and intensive care unit costs compared with usual care patients. The palliative care patients who died had an adjusted net savings of 374 in direct costs per day (P < .001) including significant reductions in pharmacy, laboratory, and intensive care unit costs compared with usual care patients. Two confirmatory analyses were performed. Including mean costs per day before palliative care and before a comparable reference day for usual care patients in the propensity score models resulted in similar results. Estimating costs for palliative care patients assuming that they did not receive palliative care resulted in projected costs that were not significantly different from usual care costs.
Hospital palliative care consultation teams are associated with significant hospital cost savings.
Delirium impedes communication and contributes to symptom distress in patients with advanced cancer. There are few prospective data on the reversal of delirium in this population.
To evaluate the occurrence, precipitating factors, and reversibility of delirium in patients with advanced cancer.
Prospective serial assessment in a consecutive cohort of 113 patients with advanced cancer. Precipitating factors were examined using standardized criteria; 104 patients met eligibility criteria.
Acute palliative care unit in a university-affiliated teaching hospital.
Delirium occurrence and reversal rates, duration, and patient survival. Strengths of association of various precipitating factors with reversal were expressed as hazard ratios (HRs) in univariate and multivariate analyses.
On admission, delirium was diagnosed in 44 patients (42%), and of the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%) of the 52 deaths. In univariate analysis, psychoactive medications, predominantly opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration (HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44; 95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR, 0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium had poorer survival rates than controls (P<.001).
Delirium is a frequent, multifactorial complication in advanced cancer. Despite its terminal presentation in most patients, delirium is reversible in approximately 50% of episodes. Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively.
Palliative care programs are becoming increasingly common in U.S. hospitals.
To quantify the growth of hospital based palliative care programs from 2000-2003 and identify hospital characteristics associated with the development of a palliative care program.
Data were obtained from the 2001-2004 American Hospital Association Annual Surveys which covered calendar years 2000-2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data.
Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor- profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than non- Catholic Church-operated hospitals and hospitals without hospice programs respectively.
Our data suggest that although growth in palliative care programs has occurred throughout the nation's hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals.
Delirium is a common syndrome in terminal cancer patients. However, its detection and treatment by palliative care teams are not well documented. This survey aimed to determine the prevalence, detection and treatment of delirium in terminal cancer inpatients.
The survey was conducted in Mackay Hospice and Palliative Care Center, Taiwan, from August 2006 to January 2007. All terminal cancer inpatients were invited to participate. The Delirium Rating Scale-Chinese Version was used by a research assistant as the screening instrument. Patients detected by screening were reviewed by psychiatrists to verify the diagnosis and determine the sub-type of delirium. The palliative care team members were asked to evaluate all the participants weekly. The medications used for delirium were obtained by a medical chart review. Result Two hundred and twenty eight participants (49.9%) among 457 inpatients were screened. The prevalence of delirium was 46.9% (n = 107). Of these, the most common subtype was hypoactive (68.2%, 95% confidence interval (CI): 59.4-77.0%). The mortality rate of inpatients with delirium (77.6%, 95% CI: 69.7-85.5%) was higher (P < 0.0001) than those without delirium (50.9%, 95% CI: 44.4-57.4%). The overall detection rate by any member of the palliative team was 44.9% (n = 48) (95% CI: 35.5-54.3%). The detection rate of the hypoactive subtype was only 20.5% (95% CI: 11.2-29.8%), which was significantly lower than that of the hyperactive/mixed subtypes (P < 0.0001). Therapy for delirium was prescribed in 42.1% (n = 45) (95% CI: 32.7-51.5%) with haloperidol being the most common medication.
The prevalence of delirium was high, but the rates of detection and treatment were low. Interventions are recommended to improve the diagnosis and treatment of delirium in palliative care units.
The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more "palliative care triggers" on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.
Purpose To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources. Patients and Methods We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program. Results Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P = .02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P < .001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P < .001), hospitalization (7.8% v 9.1%; P = .008), or were admitted to an intensive care unit (7.1% v 9.4%; P = .009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P < .001) and more used hospice services (28.3% v 38.8%; P < .001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P = .004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis. Conclusion The treatment of cancer patients near death is becoming increasingly aggressive over time.
Limited data exist concerning the unique pain characteristics of patients with non-cancer terminal diseases referred for inpatient hospice care.
To define the unique pain characteristics of patients admitted to an acute inpatient hospice setting with end-stage dementia or chronic obstructive lung disease (or chronic obstructive pulmonary disease) and to compare them to patients with end-stage cancer.
Retrospective patient chart review. Demographic, physiological, pain parameters, and medication utilization data were extracted. Associations between pain characteristics, medication utilization, and admission diagnoses were assessed. Analyses included descriptive statistics.
In total, 146 patients admitted to an acute inpatient hospice between 1 April 2011 and 31 March 2012 with an underlying primary diagnosis of chronic obstructive pulmonary disease (n = 51), dementia (n = 48), or cancer (n = 47).
Pain was highly prevalent in all diagnostic groups, with cancer patients experiencing more severe pain on admission. Cancer patients received a significantly higher cumulative opioid dose compared with dementia and chronic obstructive pulmonary disease patients. Pain control within 24 h of pain onset was achieved in less than half of all patient groups with chronic obstructive pulmonary disease patients the least likely to achieve pain control.
Despite the fact that pain is the most common complaint at the end of life, pain management may be suboptimal for some primary diagnoses. Admission diagnosis is the strongest predictor of pain control. Patient with cancer achieve the best pain control, and chronic obstructive pulmonary disease patients are the least likely to have their pain adequately treated.
© The Author(s) 2015.
Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging.
This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings.
In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care.
Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes.
Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.
Lung cancer patients visit the emergency room (ER) for cancer-related and -unrelated reasons more often compared to patients with other types of cancer. This results in increased admissions and deaths in the ER. In this study, we retrospectively reviewed the characteristics of lung cancer patients visiting the ER in order to optimize the utilization of emergency medical services and improve the patients' quality of life. Lung cancer patients visiting the ER of a single institution over a 2-year period (2010-2011) were analyzed. The patients' chief complaints and diagnoses at presentation in the ER were classified as cancer-related and -unrelated. Hospital admission, discharge from the ER, hospital mortality and survival of advanced lung cancer patients hospitalized through admission to the ER was surveyed. A total of 113 patients visited the ER 143 times. Seventy visits (49.0%) were cancer-related and 73 (51.0%) were cancer-unrelated. Respiratory symptoms, pain, gastrointestinal and neurological events and fever were the most common cancer-related issues recorded. With the progression of cancer stage, the number of ER visits, admissions, ambulance use and hospital mortalities increased. In visits due to cancer-unrelated issues, including infection, cardiovascular and gastrointestinal diseases, fever was the most common complaint. Emergency admissions of advanced-stage patients for cancer-related issues revealed a significantly shorter median survival time compared to that for patients admitted for cancer-unrelated issues (61 vs. 406 days, respectively; P<0.05). It was observed that outpatients with lung cancer visited the ER for cancer-related and -unrelated reasons with a similar frequency. Therefore, accurate differential diagnosis in the ER is crucial for patients with lung cancer.
Older adults who present to an emergency department (ED) generally have more‐complex medical conditions with complicated care needs and are at high risk for preventable adverse outcomes during their ED visit. The Care and Respect for Elders with Emergencies (CARE) volunteer initiative is a geriatric‐focused volunteer program developed to help prevent avoidable complications such as falls, delirium and use of restraints, and functional decline in vulnerable elders in the ED. The CARE program consists of bedside volunteer interventions ranging from conversation to various short activities designed to engage and reorient high‐risk, older, unaccompanied individuals in the ED. This article describes the development and characteristics of the CARE program, the services provided, the experiences of the elderly patients and their volunteers, and the growth of the program over time.
CARE volunteers provide elders with the additional attention needed in an often chaotic, unfamiliar environment by enhancing their care, improving satisfaction, and preventing potential decline.
Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology-it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.
Clinicians involved in the opioid pharmacotherapy of cancer-related pain should be acquainted with a variety of opioids and be skilled in the selection of doses when the type of opioid or route of administration needs changing. The optimal dose should avoid under-dosing or overdosing, both associated with negative outcomes for the patient. Although equianalgesic dose tables are generally used to determine the new doses in these circumstances, the evidence to support the ratios indicated in these tables largely refers to the context of single dose administration. The applicability of these ratios to the setting of chronic opioid administration has been questioned. A systematic search of published literature from 1966 to September 1999 was conducted to critically appraise the emerging evidence on equianalgesic dose ratios derived from studies of chronic opioid administration. There were six major findings: 1) there exists a general paucity of data related to long-term dosing and studies are heterogeneous in nature; 2) the ratios exhibit extremely wide ranges; 3) methadone is more potent than previously appreciated; 4) the ratios related to methadone are highly correlated with the dose of the previous opioid; 5) the ratio may change according to the direction the opioid switch; and 6) discrepancies exist with respect to both oxycodone and fentanyl. Overall, these findings have important clinical implications for clinicians and warrant consideration in the potential revision of current tables. The complexity of the clinical context in which many switches occur must be recognized and also appreciated in the design of future studies.
Introduction:
Presentations by patients with advanced illness to the Emergency Department (ED) towards the end-of-life can be distressing for both patients and caregivers. With an understanding of why patients present, interventions to avoid these presentations close to the end-of-life may be possible.
Aims:
To identify patients under the specialist palliative care service (SPCS) who attended the ED over 6 months and to determine if these presentations were potentially avoidable. Presentations were deemed avoidable if the problem could have been dealt with in another manner, i.e. by the home care team or by the family physician, or in another setting, such as by admission to the hospice.
Results:
Thirty-five ED presentations by 30 patients were included. Eighteen (60%) male, mean age 68.7 (47-89). Twenty-two (63%) ED presentations were outside working hours. The main reasons for attending were: dyspnea (9, 26%), nausea/vomiting/constipation (6, 17%) and uncontrolled pain (5, 14.5%). Thirty-three (94%) of the 35 presentations resulted in hospitalization. The average length of time spent in the ED was 9.2 hours (3-24). Referral to the hospital SPCS was made in 20 (60%) cases. Fifteen (50%) patients died within one month of presentation. Eighteen (51.5%) ED presentations were deemed potentially avoidable.
Conclusion:
Many ED presentations by palliative care patients may be avoidable. Appropriate sharing of information to on-call doctors, creating confidence in carers and providing extra practical supports is necessary. A comprehensive, coordinated specialist palliative care approach across community and acute services may help ensure patients are not sent to the ED inappropriately.
Although the information from Gover et al (2011) is comprehensive it does not include vital information for management of delirium from key studies in this area of research. This paper has summarised information as lists and tables without systematic critical appraisal. Therefore, in the absence of a robust methodology for literature search and critical appraisal of past and current literature, it has limited implications to help future management or research in the field of delirium.
Motor subtypes have promise as a means of identifying clinically relevant delirium subgroups. Little is known about their relationship to etiologies, medication exposure, and outcomes.
Consecutive cases of DSM-IV delirium in palliative care patients were assessed twice-weekly throughout their delirium episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Etiology Checklist (DEC) and Delirium Rating Scale Revised-98 (DRS-R98).
100 patients [mean age 70.2 ± 10.5] were assessed on 303 visits [range 2-9]. Over the entire episode, mean DRS-R98 Severity scores were 16.2 ± 5.7. The mean number of etiologies per case was 3.4 ± 1.2. Motor subtypes were no subtype throughout (6%), hypoactive subtype throughout (28%), mixed subtype throughout (18%), hyperactive subtype throughout (10%) and variable subtype (38%). DRS-R98 Total and Severity scales differed significantly across categories (highest in mixed) but only motor, sleep-wake cycle, perceptual and language disturbance items differed. The Generalized Estimating Equations (GEE) approach was used to explore the relationship between subtype profile and symptoms, medication exposure and etiology. This showed that apart from motor items, only delusions, affective lability, metabolic disturbance and CVA related to any subtype. Cross-sectional assessments indicated greater use of benzodiazepine and antipsychotics in hyperactive patients but GEE analyses did not identify major associations between motor subtype and medication exposure. Patients with sustained hypoactive subtype were significantly more likely to die within one month of study entry.
Motor profile in delirium is relatively consistent over episode course and relates more closely to delirium phenomenology than to etiology or medication exposure. Motor subtypes have comparable disturbance of key diagnostic features such as cognitive and thought process abnormalities. Although mixed subtype is the most phenomenologically intense, hypoactives have the poorest prognosis.
A rapid two-stage screening protocol was developed to improve referral for palliative care needs among frail elderly in the emergency department (ED).
A new triage tool was administered, with assessment tools for activities of daily living, performance, functional staging, symptom burden, and caregiver distress.
Stage One identified elderly patients meeting criteria for life-limiting conditions. Stage Two referred patients with crescendo losses in activities of daily living, high symptom burden, and caregiver distress to palliative care or hospice.
Over eight months, 1587 patients were screened, representing 22% of ED visits made by patients older than 65 years during this time period. Of these, 140 met functional decline criteria, and 51 of these needed palliative care consultation. Five patients were referred to hospice, 20 received palliative care, and 26 received no further service. CONCLUSIONS/LESSONS LEARNED: The project shows unmet needs among elderly ED patients, and the feasibility of rapid screening and referral using a quality improvement approach. At its peak, the project accounted for half the referrals to the palliative care consultation service.
A small proportion of patients with serious illness or multiple chronic conditions account for the majority of health care spending. Despite the high cost, evidence demonstrates that these patients receive health care of inadequate quality, characterized by fragmentation, overuse, medical errors, and poor quality of life.
This article examines data demonstrating the impact of the U.S. health care system on clinical care outcomes and costs for the sickest and most vulnerable patients. It also defines palliative care and hospice, synthesizes studies of the outcomes of palliative care and hospice services, reviews variables predicting access to palliative care and hospice services, and identifies those policy priorities necessary to strengthen access to high-quality palliative care.
Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Some data suggest that, compared with the usual care, palliative care prolongs life. By helping patients get the care they need to avoid unnecessary emergency department and hospital stays and shifting the locus of care to the home or community, palliative care and hospice reduce health care spending for America's sickest and most costly patient populations.
Policies focused on enhancing the palliative care workforce, investing in the field's science base, and increasing the availability of services in U.S. hospitals and nursing homes are needed to ensure equitable access to optimal care for seriously ill patients and those with multiple chronic conditions.
Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams.
To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED.
Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews.
Twenty emergency physicians participated (mean age 41 years, range 31-61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine-to provide stabilization of acute medical emergencies-was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician's responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family.
Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.
At advanced stages, cancer, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) produce high rates of hospitalization, disability, and annual mortality. Despite similar prognoses, patients with cancer often are treated differently than those with other illnesses, the former being seen as terminal vs. chronic.
The purpose of this study was to compare the functional capacity, emotional well-being, and quality of life of patients in three disease groups to assess whether diagnosis distinguishes differences in patient experience, and compare patients with cancer and noncancer diagnoses.
Baseline data from a cohort study of 210 patients who had an estimated 50% two-year mortality were analyzed. The patients had Stage IV breast, prostate, or colon cancer; Stage IIIb or IV lung cancer; New York Heart Association Stage III or IV CHF with a left ventricular ejection fraction of <40%; or COPD with hypercapnea (pC02>46) and at least one hospitalization or Emergency Department visit during the past year. Measures included the Rosow-Breslau Activities of Daily Living/Instrumental Activities of Daily Living tool, Profile of Mood States anxiety subscale, brief Centers for Epidemiologic Studies Depression Scale, and the Functional Assessment of Cancer Therapy-General quality-of-life instrument. Analyses included descriptive statistics, analysis of variance, and adjusted linear regression models.
A majority of illness outcomes did not differ by diagnostic category. Functional status was associated with diagnosis, with CHF and COPD patients faring worse than those with cancer. Overall, illness experience was most significantly related to disease severity, demographics, and emotional and social well-being.
Comparing patients with advanced cancer, CHF, and COPD, illness experience was more similar than different. Patients living with life-limiting illnesses other than cancer may benefit from whole-person services often extended to cancer patients.
The objective was to identify the palliative care needs of seriously ill, older adults in the emergency department (ED).
The authors conducted a cross-sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end-stage liver or renal disease, stroke, oxygen-dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face-to-face interviews were conducted using the Needs Near the End-of-Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well-being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient-clinician relationship, and 9) overall quality of life (QOL).
Mean (±SD) age was 74.3 (±6.5) years and cancer was the most common diagnosis. Mean (±SD) QOL on the MQOL was 3.6 (±2.9). Over half of the patients exceeded intratest severity-of-needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS.
Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs.
The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes.
The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training.
This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project.
In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions.
The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.
Delirium is a frequent complication in oncology. Its definition as a disorder of consciousness, attention, and cognition is useful to elaborate a rational framework of its pathophysiology and to interpret the role of different aetiological factors and therapeutic interventions. Many aetiologies and an interaction between risk and predisposing factors have been shown to contribute to most cases of delirium. A screening of potential aetiologies is always mandatory to benefit reversible cases. The palliative treatment of symptoms of delirium includes non-pharmacological, environmental, and preventive interventions and the use of haloperidol. If haloperidol fails to control delirium, sedation with other drugs can be necessary. Specific attention to the qualitative aspects of care and to the effect of delirium on family members should be given in the overall assessment of the patient in his or her cancer trajectory.
Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.
We conducted a systematic examination of the experience of delirium in a sample of 154 hospitalized patients with cancer. Patients all met DSM-IV criteria for delirium and were rated with the Memorial Delirium Assessment Scale as a measure of delirium severity, phenomenology, and resolution. Of the 154 patients assessed, 101 had complete resolution of their delirium and were administered the Delirium Experience Questionnaire (DEQ-a face-valid measure that assesses delirium recall and distress related to the delirium episode). Spouse/caregivers and primary nurses were also administered the DEQ to assess distress related to caring for a delirious patient. Fifty-four (53.5%) patients recalled their delirium experience. Logistic-regression analysis demonstrated that short-term memory impairment (odds ratio [OR] = 38.4), delirium severity (OR = 11.3), and the presence of perceptual disturbances (OR = 6.9) were significant predictors of delirium recall. Mean delirium-related distress levels (on a 0-4 numerical rating scale of the DEQ) were 3.2 for patients who recalled delirium, 3.75 for spouses/caregivers, and 3.09 for nurses. Logistic-regression analysis demonstrated that the presence of delusions (OR = 7.9) was the most significant predictor of patient distress. Patients with "hypoactive" delirium were just as distressed as patients with "hyperactive" delirium. Karnofsky Performance Status (OR = 9.1) was the most significant predictor of spouse/caregiver distress. Delirium severity (OR =5.2) and the presence of perceptual disturbances (OR =3.6) were the most significant predictors of nurse distress. In conclusion, a majority of patients with delirium recall their delirium as highly distressing. Delirium is also a highly distressing experience for spouses/caregivers and nurses who are caring for delirious patients. Prompt recognition and treatment of delirium is critically important to reduce suffering and distress.
The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referred to hospice and community services had the highest symptom burden (mean number of symptoms per patient 7.21 and 7.13, respectively). This study suggests that different patient subgroups may have different needs in terms of symptoms, which will be relevant for the planning and rationalization of palliative care services.
To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources.
We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program.
Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P =.02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P <.001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P <.001), hospitalization (7.8% v 9.1%; P =.008), or were admitted to an intensive care unit (7.1% v 9.4%; P =.009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P <.001) and more used hospice services (28.3% v 38.8%; P <.001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P =.004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis.
The treatment of cancer patients near death is becoming increasingly aggressive over time.
Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer. In this study, we aimed to determine to what extent patients with progressive chronic diseases have similar symptom profiles. A systematic search of medical databases (MEDLINE, EMBASE, and PsycINFO) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer, acquired immunodeficiency syndrome (AIDS), heart disease, chronic obstructive pulmonary disease, or renal disease. Analyzing the data in a comparative table (a grid), we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases. Three symptoms-pain, breathlessness, and fatigue-were found among more than 50% of patients, for all five diseases. There appears to be a common pathway toward death for malignant and nonmalignant diseases. The designs of symptom prevalence studies need to be improved because of methodological disparities in symptom assessment and designs.
Pain in persons who receive hospice care is not fully understood. The purpose of this study was to describe the demographics, clinical characteristics, and pain intensity of persons who received hospice care in the United States from 2000-2004. Data for this study were obtained from a provider of hospice pharmacy services and included information about the hospice organization, demographics and clinical characteristics, pain intensity, and opioid analgesic prescribing. Worst pain intensity during the previous 24 hours was assessed using a 0-10 numeric rating scale (0=none, 10=worst) periodically during hospice care. During the study period, 347,555 persons received hospice services; 55.2% of these persons were female, 87.4% were Caucasian, and mean age was 75.3 years. At least one pain score was available for 156,887 (45.1%) individuals. Among persons with at least one pain score, pain was reported a mean of 2.9 times per person. Overall, mean pain intensity was mild, but severe pain was reported at least once by 20.3% of persons. Of individuals who reported severe pain at least once, mean age was 68.9 years, 53.7% were female, 78.0% were Caucasian, 7.4% were cared for in long-term care hospices, and 73.9% had a primary diagnosis of cancer. Severe pain was reported at least once by a substantial percentage of persons in this study. These data provide insight into pain reported by persons who received hospice care, and may be useful as process indicators of the quality of care.
ICU delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in 60 to 85% of patients receiving mechanical ventilation. This organ dysfunction is grossly underrecognized because a majority of patients have hypoactive or "quiet" delirium characterized by "negative" symptoms (eg, inattention and a flat affect) not alarming the treating team. Hyperactive delirium, formerly called ICU psychosis, stands out because of symptoms such as agitation that may cause harm to self or staff, but is actually rare relative to hypoactive delirium and associated with a better prognosis. Delirium is often incorrectly thought to be transient and of little consequence. After adjusting for numerous covariates, delirium is a strong, independent predictor of prolonged length of stay, reintubation, higher mortality, and cost of care. Expanded work on patient safety and recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world. This evidence-based review for physicians, nurses, respiratory therapists, and pharmacists will outline why it is imperative that patients be routinely monitored for delirium. This review will discuss modifiable risk factors for delirium, such as metabolic disturbances or potent sedative and analgesic medications. Attention to mitigating risk factors, along with recommended pharmacologic approaches such as antipsychotic medications, may provide resolution of delirium in some patients, while others will persist with refractory brain dysfunction and long-term cognitive impairment following critical illness.