Friday, March 19, 2010

Emergency Room Visits by Patients with Cancer Near End of LIfe

EmergencyImage by xparxy via Flickr
[Editor's Note (C.S.) - I would like to introduce Suzana Makowski, MD, MMM, FACP as the newest blogger to the Pallimed team. Suzana and I go back a few years when we first met at the AAHPM Annual Assembly in New Orleans. She has tremendous enthusiasm for hospice and palliative medicine and her insights reach beyond the traditional evidence-based medicine approach. She is the newly elected co-chair for the Humanities and Spirituality SIG for AAHPM and the founder of the Lois Green palliative faculty development initiative. You can also find her on Twitter if you are so inclined (@suzanakm). She will be blogging on the main blog and occasionally on the Arts and Humanities blog also. Please help me in welcoming Suzana!]

Thank you Christian! And of course to Palladius and to Patrick for welcoming me to Pallimed with a rich choice of articles to share. Somehow it seems fitting that my first post refer to an article from Canada – now that Vancouver has been warmed up by the Winter Olympics just a year before that city-of-my-dreams will be swarmed by thousands at the AAHPM assembly next year. Well, in full disclosure, the study was not conducted in Vancouver, but rather in Ontario.

During this time, when the House and Senate continue to debate healthcare reform, when policy-discussions surrounding palliative care are challenged by the tension between the quality and quantity of care, an article emerges from CAMJ (with free online full pdf access) that challenges us to rethink how to focus our resources for patients with serious, end-stage cancer. Taking the IOM’s definition of quality care as “the right care at the right time in the right place,” this article explores how and why patients with serious cancers and their caregivers seek help through the emergency rooms and boldly asks the question whether this is the best care the patient could be receiving.

The point of transition from home to hospital is usually the emergency room. It is a place, as a patient of mine admitted for severe breathlessness, in hospital with a chest tube explained, is never a place you want to spend much time, especially if you aren’t feeling well. “I try anything to avoid waiting hours first in the waiting room, and then on a thin mattress in the hallway or room whose walls are build by wisps of curtain, sometimes waiting for hours in close proximity with strangers.”

We know already that most people want to be at home with family at the end-of-life, we also know that most end up in hospital or institution. We have hypothesized that increasing access and enrollment to hospices might help people meet this goal. This article seeks to understand how frequently and why patients with end-stage cancer choose to go to the ER.

So this begs the question… what percentage of patients with cancer visit the emergency room during the last 6 months and 2 weeks of life?
Of the 91,561 patients who died of cancer between 2002 and 2005, 84% of patients visited the ER in the 6 months prior to death and 34% of patients visited in the last two weeks before death.  They outline the principle reasons for emergency room visits: primary cancer (mostly lung cancer), uncontrolled symptoms (pain, dyspnea and other non-pain symptoms), caregiver fatigue, and infection.
Top reasons for ER visits among patients with cancer:

While many of the patients studied ended up admitted to hospital, the authors – and I believe, rightly so – postulate that most may have avoided acute-level care had the quality and quantity of care had adequately supported the needs of both patient and caregiver. Instead of emergency room care, most of these patients required “either additional support to remain at home or direct transfer to a palliative care unit or residential hospice.”

Barbera and colleagues suggest that “comprehensive and coordinated” palliative care could serve the needs of most of these patients and their caregivers and meet this demand for quality and quantity of care, allowing patients to have symptoms tended to at home, in clinics, or in in-patient or residential hospice facilities.

Knowing why patients come to the emergency rooms allows us – Barbera proposes – to better define what we can do and how we can focus our efforts to help prevent many of these ER visits. In particular, they recommend the following:

1- Impeccable symptom management facilitated by sharing standardized, comprehensive symptom assessment and clinical guidelines;

2- Fluid medical records to allow for improved continuity of care (EMR?);

3- Caregiver education, to help them anticipate and cope with crises;

4- More robust and broad-reaching advance directives;

5- Increase palliative care workforce to improve access to experts in management of complex symptoms, as well as technical/mechanical needs of patients with complex/serious illness at home.

In addition to the above, I suggest adding to the list:

6- Engage the Emergency Medicine Physicians, NPs, PAs, nurses and social workers, to gain expertise in palliative care. For starters: EPEC-EM provides a broad foundation of knowledge in palliative care to emergency room clinicians. For those who want to take it up a notch: EM is one of the 9 primary specialties that recognize HPM as a subspecialty. Building this workforce could help address the needs of many of these patients once they have arrived in the ED. Any HPM board certified EM docs out there to comment?

7- Consider comprehensive palliative care medical homes that provide comprehensive palliative care seamlessly across healthcare settings. Support these initiatives with health policy innovation and reform and in doing so improve quality of care while decreasing cost. Compare emergency room use patterns in similar patient populations between communities with comprehensive palliative/hospice care programs and those without such robust programs as part of the cost-effectiveness research initiatives supported by the Senate.

Perhaps by expanding access to expertise in palliative care, across healthcare settings, people with end-stage cancer and their families would have the support needed to tend to their care – even if complex – and could avoid emergency room visits and hospitalizations.

ResearchBlogging.orgBarbera, L., Taylor, C., & Dudgeon, D. (2010). Why do patients with cancer visit the emergency department near the end of life? Canadian Medical Association Journal DOI: 10.1503/cmaj.091187

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