Despite a preference to receive end-of-life (EOL) care at home, many patients with advanced terminal illnesses actually go to the emergency department (ED) in their last months, weeks, and days of life. In fact, some hospital centers report that 40% of patients who present to the ED may be in their final 2 weeks of life.1 When patients are dying of cancer, their circumstances place crucial demands on hospital staff, which can be disruptive in several areas.
Why would a patient spend his or her final days or hours in a crowded ED? A trip to the ED of any hospital means long hours of waiting for the patient to be seen, which can be stressful for patients and caregivers—even those in relatively good health. In a paper published in the American Journal of Hospice & Palliative Medicine, researchers undertook an investigation to gain an understanding of why patients present at emergency departments during the most difficult time in their lives. The researchers hoped that understanding the behavior can help prevent it and allow patients dying of cancer to remain in their home during their last days.2
This retrospective review was undertaken by Elaine M. Wallace, MB, BCh, BAO, MRCPI, and her colleagues in the Department of Palliative Medicine, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland. They investigated why patients presented to the ED at the end of life, how the staff assessed the patient, what treatment the patient received, and what the outcome was. The researchers reviewed the records of 30 patients aged 47 to 89 years who went to the ED over a 6-month period. Their data was culled from the records from the ED, the hospital, and from the palliative care home care team.
These patients attended the ED for a number of reasons. The most common were dyspnea (nine patients, 26%), nausea and vomiting/constipation (six patients, 17%), and uncontrolled pain (five patients, 14.5%). Thirty-three of the 35 (94%) ED presentations resulted in hospitalization. Patients spent an average of 9.2 hours in the ED. Many of their visits took place after regular hours and on weekends. The hospital staff referred 20 patients (60%) to their specialized palliative care service (SPCS). Fifteen patients (50%) died within 1 month of their ED visit.
Potentially avoidable visits ED staff considered 18 of the presentations (51.5%) potentially avoidable. This meant that reasons for the ED visit were constipation; technical or mechanical reasons, such as follow-up or laboratory examination; attention to dressings or sutures; adjustment of urinary catheters; or prescription refills.2
The researchers noted that on-call general practitioners (GPs) made many of the referrals to the ED. Reasons for this trend might have been because the GPs did not know the patient or were not familiar with the patient’s treatment plan. They may have been pressured by family members to intervene. Thus the on-call physicians might have felt most comfortable referring the patient for care. However, the care was often something that could have been performed by a visiting nurse or hospice service (eg, catheter insertion, blood transfusions, IV antibiotics).
SOLVING THE PROBLEM
The primary care provider These types of difficulties should be anticipated so they can be more readily addressed when and where resources are available. Treating physicians should provide regular clinical updates to primary care providers. They should share a current medical summary with accurate diagnosis and prognosis, current treatments, medications, up-to-date management plan, and information on the patient’s preferred location for end-of-life care.
The family/caregivers The treating clinicians should keep patients’ family and caregivers informed about the therapeutic plan, whom to consult, and what to expect as the disease progresses. Despite such preparation, however, times when the family or caregivers would feel distressed and need guidance and reassurance are certain to occur. The researchers suggest that providing extra practical support to the families may play a role in maintaining their loved one in the home setting. Ongoing psychological support can also provide families with necessary reassurance.2 ONA
Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.
1. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ. 2010;182(6):563-568.
2. Wallace EM, Cooney MC, Walsh J, et al. Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care. 2013;30(3):253-256.