Initiating Palliative Care in the Emergency Department
Most patients with advanced cancer will resort to the emergency department (ED) as their disease progresses, at which time the immediate crisis will be dealt with and a future course of treatment will most likely be set. Depending on the patient's condition, a number of services will intervene, including hospice. However, despite the fact that research has shown that early palliative care intervention improve patient outcomes,1-3 it is less frequent for palliative care to be introduced in the ED.
Researchers at Mount Sinai Medical Center in New York, NY, sought to evaluate the differences between patients with advanced cancer who visit the ED and receive a palliative care consultation and those who do not receive such a consultation.4 The parameters they looked at were quality of life (QOL), depression, health care utilization, and, ultimately, survival for each patient.
Between June 2011 and April 2014 the researchers enrolled 136 patients in a single blind, randomized clinical trial. There were 67 patients in the usual care group and 69 in the palliative care intervention group. The mean age of patients was 58 and 55, respectively, and each group was divided approximately in half between male and female participants. Study criteria were that patients were diagnosed with advanced cancer, never received palliative care intervention, passed a cognitive screening, and were fluent in English or Spanish.
The hospital's palliative care team was comprised of a nurse practitioner, physician, social worker, and chaplain. The palliative care consultation was divided into 3 parts: (1) symptom assessment and treatment, (2) goals of care and advance care plans, and (3) transition planning. Team members were in touch with each patient in the study's palliative care arm, as well as with that patient's family and health care teams on a regular basis. Patients in the usual care arm could receive a palliative care consultation if the admitting or oncology teams requested it.
At 12 weeks QOL among patients in the palliative care intervention group was better than in the usual care group. In order to assess QOL the researchers used the Functional Assessment of Chronic Illness Therapy–General Measure (FACT-G) scale, where a higher score indicates a better QOL. The researchers took measurements at baseline, 6 weeks, and 12 weeks. Compared with the baseline, patients in the palliative care arm had an increase of 5.91 points on the FACT-G scale at week 12 (standard deviation, 16.65), as opposed to patients in the usual care arm whose score was 1.08 points.
Depression was not different among subjects in both groups from baseline at either week 6 or week 12.