This article is more than 5 years old. Information may no longer be current.
Initiation of palliative care in ED improves quality of life
Click Here to Manage Email Alerts
Palliative care initiated in the emergency department appeared to improve quality of life without shortening survival among patients with advanced cancer, according to results from a single blind, randomized clinical trial.
Patients with advanced cancer often visit the ED of a hospital, during which they often make decisions about intensity of care, according to study background. However, palliative care consultations typically do not occur until 1 week into a patient’s hospital stay.
Corita R. Grudzen
Because palliative care consultation is not a standard practice in most EDs, Corita R. Grudzen, MD, MSHS, associate professor in the Ronald O. Perelman Department of Emergency Medicine and in the department of population health at New York University Langone Medical Center, and colleagues sought to compare quality of life, depression, health care utilization and survival among patients with advanced cancer who received ED–initiated palliative care vs. usual care.
“Better matching of patients’ goals of care to treatments would not only result in better concordance of emergency department disposition with patients’ preferred site of care, but also might decrease ICU admissions at the end of life and increase referrals to hospice,” Grudzen and colleagues wrote. “A consultation prompted from the emergency department may be a unique point at which to ensure that care is congruent with patients’ wishes and interrupt the cascade of intensive, end-of-life care that could be a marker of low-quality care.”
The analysis included data from 136 patients with advanced cancer who visited the ED at Mount Saini Hospital between June 2011 and April 2014. Researchers randomly assigned patients to receive a palliative care intervention in the ED (n = 69; mean age, 55.1 years), or standard care (n = 67; mean age, 57.8 years). The palliative care consultation in the intervention arm occurred within a few hours of visiting the ED and consisted of symptom assessment and treatment, goals of care and advance care plans, and transition planning. Patients in the standard arm received a palliative care consultation after hospital admission if requested by the admitting team or oncologist.
The measure of the change in quality of life score at 12 weeks served as the primary outcome. Secondary outcomes included 1-year survival, health care utilization at 180 days and major depressive disorder at 12 weeks.
Quality of life — measured using the Functional Assessment of Cancer Therapy-General Measure — appeared significantly higher in the intervention group at week 12 compared with baseline (median standard deviation [SD] increase = 5.91 points) than the control group (median SD increase = 1.08; P = .03).
Additionally, the median survival estimate was longer in the intervention group (289 days; 95% CI, 128-453) than in the control arm (132 days, 95% CI, 80-302), although the researchers did not find this to be statistically significant.
There were no noted differences in depression, ICU admission, or discharge to hospice care.
“Early palliative care initiated from the emergency department improves quality of life for patients with advanced cancer, and doesn't appear to shorten survival as some might think,” Grudzen told HemOnc Today. “This means that emergency providers, who may spend just a few hours with a patient, can significantly impact a patients' quality of life weeks or months later by triggering a palliative care consult.
“The next steps in this work are to find ways to initiate palliative care in practice to make the service more widely available,” Grudzen added.
Eduardo Bruera, MD, chair of the department of palliative care and rehabilitation medicine in the division of cancer medicine at The University of Texas MD Anderson Cancer Center in Houston, wrote these results should lead to the evaluation of additional research questions.
“Where do we go from here?” Bruera wrote. “It is important to define and test criteria for palliative care referral from the emergency department in daily clinical practices. It will also be important to understand the attitudes and adherence of patients when referred to outpatient palliative care from the emergency department. In view of the findings of this study, this research is much needed and justified.” – by Anthony SanFilippo
For more information:
Corita R. Grudzen, MD, MHS, can be reached at corita.grudzen@nyumc.org.
Disclosure: The researchers and Bruera reported no relevant financial disclosures.
Perspective
Back to TopMarcin Chwistek, MD
Many patients with cancer present to the emergency department because of poorly controlled symptoms or at the time of emotional crisis. This is especially true for the most vulnerable patients — minorities and the poor — who receive care in the EDs in disproportionately high numbers.
This innovative study looks at initiating palliative care for cancer patients in the ED, right at the height of the crisis. This is often the time when crucial decisions are made, and support of the palliative care team can ensure that patients and families receive care that is aligned with their values and wishes.
Cancer patients who were seen by the palliative care team in the ED and then followed had a better quality of life than patients who were treated routinely, confirming the findings from the previous palliative care studies.
Click Here to Manage Email Alerts