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Open Access 01-03-2020 | Care | Original Article

Palliative care needs of advanced cancer patients in the emergency department at the end of life: an observational cohort study

Authors: Mary-Joanne Verhoef, Ellen de Nijs, Nanda Horeweg, Jaap Fogteloo, Christian Heringhaus, Anouk Jochems, Marta Fiocco, Yvette van der Linden

Published in: Supportive Care in Cancer | Issue 3/2020

Abstract

Purpose

Patients with advanced cancer commonly visit the emergency department (ED) during the last 3 months of life. Identification of these patients and their palliative care needs help initiating appropriate care according to patients’ wishes. Our objective was to provide insight into ED visits of advanced cancer patients at the end of life.

Methods

Adult palliative patients with solid tumours who died < 3 months after their ED visit were included (2011–2014). Patients, ED visits, and follow-up were described. Factors associated with approaching death were assessed using Cox proportional hazards models.

Results

Four hundred twenty patients were included, 54.5% was male, median age 63 years. A total of 54.6% was on systemic anti-cancer treatments and 10.5% received home care ≥ 1 per day. ED visits were initiated by patients and family in 34.0% and 51.9% occurred during out-of-office hours. Dyspnoea (21.0%) or pain (18.6%) were most reported symptoms. Before the ED visit, limitations on life-sustaining treatments were discussed in 33.8%, during or after the ED visit in 70.7%. Median stay at the ED was 3:29 h (range 00:12–18:01 h), and 319 (76.0%) were hospitalized. Median survival was 18 days (IQ range 7–41). One hundred four (24.8%) died within 7 days after the ED visit, of which 71.2% in-hospital. Factors associated with approaching death were lung cancer, neurologic deterioration, dyspnoea, hypercalcemia, and jaundice.

Conclusion

ED visits of advanced cancer patients often lead to hospitalization and in-hospital deaths. Timely recognition of patients with limited life expectancies and urgent palliative care needs, and awareness among ED staff of the potential of ED-initiated palliative care may improve the end-of-life trajectory of these patients.

Global Burden of Disease Cancer C, Fitzmaurice C, Akinyemiju TF, Al Lami FH, Alam T, Alizadeh-Navaei R, Allen C, Alsharif U, Alvis-Guzman N, Amini E, Anderson BO, Aremu O, Artaman A, Asgedom SW, Assadi R, Atey TM, Avila-Burgos L, Awasthi A, Ba Saleem HO, Barac A, Bennett JR, Bensenor IM, Bhakta N, Brenner H, Cahuana-Hurtado L, Castaneda-Orjuela CA, Catala-Lopez F, Choi JJ, Christopher DJ, Chung SC, Curado MP, Dandona L, Dandona R, das Neves J, Dey S, Dharmaratne SD, Doku DT, Driscoll TR, Dubey M, Ebrahimi H, Edessa D, El-Khatib Z, Endries AY, Fischer F, Force LM, Foreman KJ, Gebrehiwot SW, Gopalani SV, Grosso G, Gupta R, Gyawali B, Hamadeh RR, Hamidi S, Harvey J, Hassen HY, Hay RJ, Hay SI, Heibati B, Hiluf MK, Horita N, Hosgood HD, Ilesanmi OS, Innos K, Islami F, Jakovljevic MB, Johnson SC, Jonas JB, Kasaeian A, Kassa TD, Khader YS, Khan EA, Khan G, Khang YH, Khosravi MH, Khubchandani J, Kopec JA, Kumar GA, Kutz M, Lad DP, Lafranconi A, Lan Q, Legesse Y, Leigh J, Linn S, Lunevicius R, Majeed A, Malekzadeh R, Malta DC, Mantovani LG, McMahon BJ, Meier T, Melaku YA, Melku M, Memiah P, Mendoza W, Meretoja TJ, Mezgebe HB, Miller TR, Mohammed S, Mokdad AH, Moosazadeh M, Moraga P, Mousavi SM, Nangia V, Nguyen CT, Nong VM, Ogbo FA, Olagunju AT, Pa M, Park EK, Patel T, Pereira DM, Pishgar F, Postma MJ, Pourmalek F, Qorbani M, Rafay A, Rawaf S, Rawaf DL, Roshandel G, Safiri S, Salimzadeh H, Sanabria JR, Santric Milicevic MM, Sartorius B, Satpathy M, Sepanlou SG, Shackelford KA, Shaikh MA, Sharif-Alhoseini M, She J, Shin MJ, Shiue I, Shrime MG, Sinke AH, Sisay M, Sligar A, Sufiyan MB, Sykes BL, Tabares-Seisdedos R, Tessema GA, Topor-Madry R, Tran TT, Tran BX, Ukwaja KN, Vlassov VV, Vollset SE, Weiderpass E, Williams HC, Yimer NB, Yonemoto N, Younis MZ, Murray CJL, Naghavi M (2018) Global, regional, and National Cancer Incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 Cancer groups, 1990 to 2016: a systematic analysis for the global burden of disease study. JAMA Oncol 4:1553–1568. https://doi.org/10.1001/jamaoncol.2018.2706 CrossRef

World Health Organization (2018) WHO Definition of Palliative Care. http://www.who.int/cancer/palliative/definition/en/. Accessed 5 Oct 2018

Gomes B, Higginson IJ, Calanzani N, Cohen J, Deliens L, Daveson BA, Bechinger-English D, Bausewein C, Ferreira PL, Toscani F, Menaca A, Gysels M, Ceulemans L, Simon ST, Pasman HR, Albers G, Hall S, Murtagh FE, Haugen DF, Downing J, Koffman J, Pettenati F, Finetti S, Antunes B, Harding R, Prisma (2012) Preferences for place of death if faced with advanced cancer: a population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. Ann Oncol 23(8):2006–2015. https://doi.org/10.1093/annonc/mdr602 CrossRefPubMed

Higginson IJ, Sen-Gupta GJ (2000) Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 3(3):287–300. https://doi.org/10.1089/jpm.2000.3.287 CrossRefPubMed

Barbera L, Taylor C, Dudgeon D (2010) Why do patients with cancer visit the emergency department near the end of life? CMAJ 182(6):563–568. https://doi.org/10.1503/cmaj.091187 CrossRefPubMedPubMedCentral

Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22(2):315–321. https://doi.org/10.1200/JCO.2004.08.136 CrossRefPubMed

Qureshi D, Tanuseputro P, Perez R, Seow H (2018) Place of Care trajectories in the last two Weeks of life: a population-based cohort study of Ontario decedents. J Palliat Med 21:1588–1595. https://doi.org/10.1089/jpm.2018.0049 CrossRefPubMedPubMedCentral

Mayer DK, Travers D, Wyss A, Leak A, Waller A (2011) Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol 29(19):2683–2688. https://doi.org/10.1200/JCO.2010.34.2816 CrossRefPubMedPubMedCentral

Geraci JM, Tsang W, Valdres RV, Escalante CP (2006) Progressive disease in patients with cancer presenting to an emergency room with acute symptoms predicts short-term mortality. Support Care Cancer 14(10):1038–1045. https://doi.org/10.1007/s00520-006-0053-6 CrossRefPubMed

10.

Mercadante S, Porzio G, Valle A, Aielli F, Costanzo V, Adile C, Spedale V, Casuccio A, Home Care Italy G (2012) Emergencies in patients with advanced cancer followed at home. J Pain Symptom Manag 44(2):295–300. https://doi.org/10.1016/j.jpainsymman.2011.07.016 CrossRef

11.

Mercadante S, Masedu F, Valenti M, Mercadante A, Aielli F (2016) The characteristics of advanced cancer patients followed at home, but admitted to the hospital for the last days of life. Intern Emerg Med 11(5):713–718. https://doi.org/10.1007/s11739-016-1402-1 CrossRefPubMed

12.

Henson LA, Higginson IJ, Daveson BA, Ellis-Smith C, Koffman J, Morgan M, Gao W, BuildCare (2016) I'll be in a safe place': a qualitative study of the decisions taken by people with advanced cancer to seek emergency department care. BMJ Open 6(11):e012134. https://doi.org/10.1136/bmjopen-2016-012134 CrossRefPubMedPubMedCentral

13.

Cooper E, Hutchinson A, Sheikh Z, Taylor P, Townend W, Johnson MJ (2018) Palliative care in the emergency department: a systematic literature qualitative review and thematic synthesis. Palliat Med 32:1443–1454. https://doi.org/10.1177/0269216318783920 CrossRefPubMed

14.

Jelinek GA, Marck CH, Weiland TJ, Philip J, Boughey M, Weil J, Lane H (2013) Caught in the middle: tensions around the emergency department care of people with advanced cancer. Emerg Med Australas 25(2):154–160. https://doi.org/10.1111/1742-6723.12047 CrossRefPubMed

15.

Smith AK, Fisher J, Schonberg MA, Pallin DJ, Block SD, Forrow L, Phillips RS, McCarthy EP (2009) Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 54(1):86–93, 93 e81. https://doi.org/10.1016/j.annemergmed.2008.08.022 CrossRefPubMed

16.

Marck CH, Weil J, Lane H, Weiland TJ, Philip J, Boughey M, Jelinek GA (2014) Care of the dying cancer patient in the emergency department: findings from a national survey of Australian emergency department clinicians. Intern Med J 44(4):362–368. https://doi.org/10.1111/imj.12379 CrossRefPubMed

17.

Lane H, Weil J, Jelinek GA, Boughey M, Marck CH, Weiland TJ, Haydon A, Philip J (2014) Ideal care and the realities of practice: interdisciplinary relationships in the management of advanced cancer patients in Australian emergency departments. Support Care Cancer 22(4):1029–1035. https://doi.org/10.1007/s00520-013-2054-6 CrossRefPubMed

18.

Hui D (2015) Prognostication of survival in patients with advanced Cancer: predicting the unpredictable? Cancer Control 22(4):489–497. https://doi.org/10.1177/107327481502200415 CrossRefPubMed

19.

Lynn Joanne ADM (2003) Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. RAND Health, Santa MonicaCrossRef

20.

Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP (1982) Toxicity and response criteria of the eastern cooperative oncology group. Am J Clin Oncol 5(6):649–655CrossRefPubMed

21.

Smith AK, Schonberg MA, Fisher J, Pallin DJ, Block SD, Forrow L, McCarthy EP (2010) Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers. J Pain Symptom Manag 39(6):972–981. https://doi.org/10.1016/j.jpainsymman.2009.10.004 CrossRef

22.

Stone SC, Mohanty S, Grudzen CR, Shoenberger J, Asch S, Kubricek K, Lorenz KA (2011) Emergency medicine physicians' perspectives of providing palliative care in an emergency department. J Palliat Med 14(12):1333–1338. https://doi.org/10.1089/jpm.2011.0106 CrossRefPubMed

23.

Decker K, Lee S, Morphet J (2015) The experiences of emergency nurses in providing end-of-life care to patients in the emergency department. Australas Emerg Nurs J 18(2):68–74. https://doi.org/10.1016/j.aenj.2014.11.001 CrossRefPubMed

24.

Shearer FM, Rogers IR, Monterosso L, Ross-Adjie G, Rogers JR (2014) Understanding emergency department staff needs and perceptions in the provision of palliative care. Emerg Med Australas 26(3):249–255. https://doi.org/10.1111/1742-6723.12215 CrossRefPubMed

25.

Korte-Verhoef R (2014) Reasons and Avoidability of Hospitalisations at the End of Life. Perspectives of GPs, Nurses and Family Carers. VU University Medical Center, Ede

26.

Wallace EM, Cooney MC, Walsh J, Conroy M, Twomey F (2013) Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care 30(3):253–256. https://doi.org/10.1177/1049909112447285 CrossRefPubMed

27.

Delgado-Guay MO, Kim YJ, Shin SH, Chisholm G, Williams J, Allo J, Bruera E (2015) Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care. J Pain Symptom Manag 49(3):497–504. https://doi.org/10.1016/j.jpainsymman.2014.07.007 CrossRef

28.

Lopez-Acevedo M, Havrilesky LJ, Broadwater G, Kamal AH, Abernethy AP, Berchuck A, Alvarez Secord A, Tulsky JA, Valea F, Lee PS (2013) Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer. Gynecol Oncol 130(1):156–161. https://doi.org/10.1016/j.ygyno.2013.04.010 CrossRefPubMed

29.

Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, Earle CC, Weeks JC (2012) Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol 30(35):4387–4395. https://doi.org/10.1200/JCO.2012.43.6055 CrossRefPubMedPubMedCentral

30.

Henson LA, Gao W, Higginson IJ, Smith M, Davies JM, Ellis-Smith C, Daveson BA (2015) Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. J Clin Oncol 33(4):370–376. https://doi.org/10.1200/JCO.2014.57.3568 CrossRefPubMed

31.

Spilsbury K, Rosenwax L, Arendts G, Semmens JB (2017) The Association of Community-Based Palliative Care with Reduced Emergency Department Visits in the last year of life varies by patient factors. Ann Emerg Med 69(4):416–425. https://doi.org/10.1016/j.annemergmed.2016.11.036 CrossRefPubMed

32.

Spilsbury K, Rosenwax L, Arendts G, Semmens JB (2017) The impact of community-based palliative care on acute hospital use in the last year of life is modified by time to death, age and underlying cause of death. A population-based retrospective cohort study. PLoS One 12(9):e0185275. https://doi.org/10.1371/journal.pone.0185275 CrossRefPubMedPubMedCentral

33.

Haun MW, Estel S, Rucker G, Friederich HC, Villalobos M, Thomas M, Hartmann M (2017) Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev (6):CD011129. https://doi.org/10.1002/14651858.CD011129.pub2

34.

Wright CM, Youens D, Moorin RE (2018) Earlier initiation of community-based palliative Care is associated with fewer unplanned hospitalizations and emergency department presentations in the final months of life: a population-based study among Cancer decedents. J Pain Symptom Manag 55(3):745–754 e748. https://doi.org/10.1016/j.jpainsymman.2017.11.021 CrossRef

35.

Vanbutsele G, Pardon K, Van Belle S, Surmont V, De Laat M, Colman R, Eecloo K, Cocquyt V, Geboes K, Deliens L (2018) Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial. Lancet Oncol 19(3):394–404. https://doi.org/10.1016/S1470-2045(18)30060-3 CrossRefPubMed

36.

Kistler EA, Sean Morrison R, Richardson LD, Ortiz JM, Grudzen CR (2015) Emergency department-triggered palliative care in advanced cancer: proof of concept. Acad Emerg Med 22(2):237–239. https://doi.org/10.1111/acem.12573 CrossRefPubMed

37.

Grudzen CR, Richardson LD, Johnson PN, Hu M, Wang B, Ortiz JM, Kistler EA, Chen A, Morrison RS (2016) Emergency department-initiated palliative Care in Advanced Cancer: a randomized clinical trial. JAMA Oncol 2:591–598. https://doi.org/10.1001/jamaoncol.2015.5252 CrossRefPubMed

38.

Hui D, Hannon BL, Zimmermann C, Bruera E (2018) Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin 68(5):356–376. https://doi.org/10.3322/caac.21490 CrossRefPubMedPubMedCentral

39.

Hui D, Mori M, Watanabe SM, Caraceni A, Strasser F, Saarto T, Cherny N, Glare P, Kaasa S, Bruera E (2016) Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol 17(12):e552–e559. https://doi.org/10.1016/S1470-2045(16)30577-0 CrossRefPubMed

40.

Hui D, Bruera E (2017) The Edmonton symptom assessment system 25 years later: past, present, and future developments. J Pain Symptom Manag 53(3):630–643. https://doi.org/10.1016/j.jpainsymman.2016.10.370 CrossRef

41.

Hoerger M, Greer JA, Jackson VA, Park ER, Pirl WF, El-Jawahri A, Gallagher ER, Hagan T, Jacobsen J, Perry LM, Temel JS (2018) Defining the elements of early palliative Care that are associated with patient-reported outcomes and the delivery of end-of-life Care. J Clin Oncol 36(11):1096–1102. https://doi.org/10.1200/JCO.2017.75.6676 CrossRefPubMedPubMedCentral

42.

Barbera L, Atzema C, Sutradhar R, Seow H, Howell D, Husain A, Sussman J, Earle C, Liu Y, Dudgeon D (2013) Do patient-reported symptoms predict emergency department visits in cancer patients? A population-based analysis. Ann Emerg Med 61(4):427–437 e425. https://doi.org/10.1016/j.annemergmed.2012.10.010 CrossRefPubMed

43.

Downar J, Goldman R, Pinto R, Englesakis M, Adhikari NK (2017) The "surprise question" for predicting death in seriously ill patients: a systematic review and meta-analysis. CMAJ 189(13):E484–E493. https://doi.org/10.1503/cmaj.160775 CrossRefPubMedPubMedCentral

44.

Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S, Glare P, Nabal M, Vigano A, Larkin P, De Conno F, Hanks G, Kaasa S, Steering Committee of the European Association for Palliative C (2005) Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the steering Committee of the European Association for palliative Care. J Clin Oncol 23(25):6240–6248. https://doi.org/10.1200/JCO.2005.06.866 CrossRefPubMed

45.

Trajkovic-Vidakovic M, de Graeff A, Voest EE, Teunissen SC (2012) Symptoms tell it all: a systematic review of the value of symptom assessment to predict survival in advanced cancer patients. Crit Rev Oncol Hematol 84(1):130–148. https://doi.org/10.1016/j.critrevonc.2012.02.011 CrossRefPubMed

46.

de Graeff A KR (2009) Richtlijn Hypercalciemie. https://www.oncoline.nl/hypercalciemie. Accessed 16-08-2018

47.

Seow H, Barbera L, Sutradhar R, Howell D, Dudgeon D, Atzema C, Liu Y, Husain A, Sussman J, Earle C (2011) Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol 29(9):1151–1158. https://doi.org/10.1200/JCO.2010.30.7173 CrossRefPubMed

48.

Evans C, McCarthy M (1985) Prognostic uncertainty in terminal care: can the Karnofsky index help? Lancet 1(8439):1204–1206CrossRefPubMed

49.

George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J (2015) Content validation of a novel screening tool to identify emergency department patients with significant palliative Care needs. Acad Emerg Med 22(7):823–837. https://doi.org/10.1111/acem.12710 CrossRefPubMed

50.

Reuter Q, Marshall A, Zaidi H, Sista P, Powell ES, McCarthy DM, Dresden SM (2019) Emergency department-based palliative interventions: a novel approach to palliative Care in the Emergency Department. J Palliat Med. https://doi.org/10.1089/jpm.2018.0341 CrossRefPubMed

Title: Palliative care needs of advanced cancer patients in the emergency department at the end of life: an observational cohort study
Authors: Mary-Joanne Verhoef
Ellen de Nijs
Nanda Horeweg
Jaap Fogteloo
Christian Heringhaus
Anouk Jochems
Marta Fiocco
Yvette van der Linden
Publication date: 01-03-2020
Publisher: Springer Berlin Heidelberg
Keywords: Care
Hypercalcemia
Published in: Supportive Care in Cancer / Issue 3/2020
Print ISSN: 0941-4355
Electronic ISSN: 1433-7339
DOI: https://doi.org/10.1007/s00520-019-04906-x

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