Initiating palliative care in the ED for patients with advanced cancer appears to improve quality of life and does not shorten survival, according to a study. The ED should be considered an important place to initiate palliative care consultations for these patients.

Visits to the ED are common among patients with advanced cancer often because these individuals are prone to suffering from physical and/or psychological crises. During these visits, decisions are made about the intensity of care, including whether to admit the patient and whether to begin life-sustaining therapies. More hospitals throughout the United States are making palliative care services available, but consultations about this care typically do not occur until a week into a patient’s hospital stay. The ED is an important decision point at which physicians can set the care trajectory during hospitalization.

Patients with advanced cancer tend to be most concerned about maintaining control, relieving burden, and strengthening family relationships, according to previous research. Physicians often will not initiate discussions about the patient’s goals of care despite the fact that studies show that these conversations are well received by patients and can cause less distress.

Published research suggests that early palliative care consultations can improve quality of life (QOL), decrease hospital length of stay and ICU admissions, and may extend life. By better matching the goals of care to treatments, it is possible to improve concordance of ED disposition with patients’ preferred site of care. These efforts may also decrease ICU admissions at the end of life and increase referrals to hospice. A consultation prompted in the ED setting may provide a unique opportunity to ensure that care is congruent with the wishes of patients, says Corita R. Grudzen, MD, MSHS, FACEP.

 


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An Important Comparison

For a study published in JAMA Oncology, Dr. Grudzen and colleagues compared QOL, depression, healthcare utilization, and survival for ED patients with advanced cancer with regard to ED-initiated palliative care consultations versus care as usual. Intervention patients received an early comprehensive palliative care consultation by the inpatient team, which included an assessment of symptoms, spiritual and/or social needs, and goals of care. Usual care could also include palliative care, but these consults occurred less frequently than those for the intervention group recipients.

The primary outcome of the study was QOL, which was measured by changes in scores of the Functional Assessment of Cancer Therapy–General Measure (FACT-G) at 12 weeks. Secondary outcomes included examining major depressive disorder (MDD), which was measured by the Patient Health Questionnaire-9, in addition to healthcare utilization at 180 days and survival at 1 year.

Of the 136 participants enrolled in the randomized clinical trial, 69 were allocated to palliative care whereas 67 received usual care. “Our results showed that QOL was significantly higher for patients randomized to the intervention group when compared with the usual care group when we assessed them at 12 weeks after the study was initiated,” says Dr. Grudzen. Patients in the intervention group had an average increase of 5.91 points in FACT-G score from enrollment to Week 12, compared with a 1.08 point change in FACT-G score that was observed for the control group.

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This figure depicts mean changes in quality of life (QOL) scores among intervention and usual care groups at 6 and 12 weeks after initiation of the study.

“The median estimated survival was also longer for patients receiving ED-initiated palliative care consultations when compared with those receiving usual care,” Dr. Grudzen says. Intervention recipients lived nearly 5 months longer than those receiving usual care. She notes, however, that this finding did not reach statistical significance. In addition, depression was well balanced between the intervention group and the usual care group at baseline. The research team observed no significant differences with regard to MDD at Week 6 or Week 12 from baseline between the two groups.

Exploring the Implications

While these findings are critical considerations for patients, they are also important to hospitals and policymakers who are concerned with initiating palliative care earlier in the course of cancer, according to Dr. Grudzen. “Given the diversity of the ED patient population and its often limited access to specialty care, the ED is an important place to initiate palliative care consultation,” she says.

The study authors noted that QOL improvements occurred despite tremendous racial, ethnic, and socioeconomic diversity in the study cohort. In addition, the survival benefit seen among intervention recipients may be useful for ED personnel who encounter patients with advanced cancer. “Although there was great heterogeneity among survivors, our results should be reassuring to hospitals seeking to initiate palliative care triggers from the ED,” says Dr. Grudzen. The results should also provoke more interest among policymakers that wish to find ways to decrease disparities in access to palliative care.

Looking Into the Future

The impact of ED-initiated palliative care consultations on depression, hospital days, ICU admission, and hospice requires more research. “We need to find better ways of measuring whether care plans are congruent with patient goals and find ways to automate palliative care consultations among ED patients presenting with advanced cancer,” Dr. Grudzen says. “While this may be a daunting challenge, it’s an important one to explore because these patients present to the ED for a variety of physical, social, and psychological reasons.” Addressing these issues during an inpatient stay takes time but is critical to the planning of a patient’s goals regarding the pursuit of invasive care, life-sustaining procedures, admission to the ICU, or discharge to hospice.

References

Grudzen CR, Richardson LD, Johnson PN, et al. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial. JAMA Oncol. 2016 Jan 14 [Epub ahead of print]. Available at: http://oncology.jamanetwork.com/article.aspx?articleid=2481021.

Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad EmergMed. 2010;17:1253-1257.

Grudzen CR, Stone SC, Mohanty SA, et al. “I want to be takingmy own last breath”: patients’ reflections on illness when presenting to the emergency department at the end of life. J Palliat Med. 2011;14:293-296.

Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182:563-568.