The role of emergency departments in identifying, managing and referring patients with palliative care needs

Introduction

Emergency departments (EDs) in most developed countries are designed and staffed to deal with the unpredictable influx of patients with acute medical, surgical/injury, and mental health/addiction conditions. Many publicly funded EDs are experiencing a crisis in crowding, defined as a situation where the acute care needs of the arriving patients cannot be met by the emergency staff within a reasonable and timely fashion. Crowding in the ED can be best understood using the conceptual model describing several interconnected components including input (e.g., ambulance arrival, ambulatory presentations, transfers), throughput (e.g., laboratory and imaging, fast-track/rapid assessment areas, consultations), output (e.g., access block, access to long-term care) and system-wide (e.g., clinician payment structure, health system) factors that can lead to overcrowding (Figure 1) (1).

Figure 1 The conceptual model for explaining emergency department crowding. Adapted from Asplin et al. Ann Emerg Med 2003;42:173-80 (1).

Since many EDs are crowded, delays are common, and many patients require timely assessment and interventions to mitigate poor outcomes. Evidence suggests that patients who have protracted stays in the ED are more often admitted and die, even when controlling for other factors (2). Patients who are frail, elderly, severely ill, or suffering may be at particular risk for negative outcomes (2) and efforts to provide timely care, improve patient flow, and improve outcomes for these patients in the ED are a public health crisis that needs urgent attention.

Palliative care (PC) patients in the ED

Not only are EDs more crowded, but the patients presenting are also older and more complex, requiring more thorough investigations. Patients with chronic illnesses including cancer, heart failure, pulmonary disease, chronic neurological disorders (e.g., dementia, parkinsonism, and multiple sclerosis), chronic renal failure and chronic gastrointestinal conditions (e.g., cirrhosis) are increasingly prevalent in the ED. While new and successful treatments have allowed hope and life longevity for many patients with these chronic illnesses, when these conditions become end-stage, patients and family/caregivers are often left with limited options to relieve suffering and they present to the ED for symptom relief and management. PC provided by primary care and/or emergency clinicians, who are not PC specialists, is often referred to as “primary” PC (3). Interviews with emergency physicians and nurses have identified a lack of training and resources as some of the challenges they face in addressing the palliative needs of patients in the ED (4).

Recent prospective studies in the ED have demonstrated that nearly 3% of patients presenting to adult EDs could be classified as having end-of-life conditions, however, this proportion varies among EDs (5,6). Moreover, patients with end-of-life conditions often have a history of multiple ED presentations prior to and following their index visit. Once in the ED, these patients consumed impressive resources, languished for many hours in crowded EDs, and were often admitted (5). The majority of presentations (78%) were made by patients with unmet PC needs; however, consultations and post-discharge referrals to PC services were infrequently requested, suggesting that more patients are suitable for referral to palliative services than are actually receiving them (6).

Most importantly, many of these patients had goals of care (GOC) that were not available to ED physicians at the time of their visit, either because these discussions had not occurred, the documentation did not accompany the patient, or due to variations among care providers as to the timing of these discussions. Systematic review evidence suggests the existence and availability of documents regarding the wishes of patients among ED patients is low in general and below 50% in the geriatric population (7). Even when present, some of these GOC decisions were deemed inappropriate by the treating clinicians at the time of the encounter, reflecting the changing nature of this designation (5). Since information gaps related to GOC create confusion for treating clinicians, angst among family members and potential medical-legal concerns, efforts to eliminate them have been the focus of attention, especially since the start of the coronavirus disease of 2019 (COVID-19) pandemic (8,9).

Interventions

Given the frequency of presentation of patients with end-of-life conditions, the ED offers an opportunity to initiate PC referrals for older adults with serious, life-limiting illness. In fact, the Choosing Wisely campaign by emergency physicians in the USA promotes this issue as a priority (don’t delay in engaging available palliative and hospice services in the ED for patients likely to benefit). It’s important to recognize that screening and identification of patients with end-of-life conditions who may need PC assessment is not simple. A systematic review of the literature identified many tools for screening patients with unmet PC needs; however, there is no consensus on their reliability and validity (10). One possible tool is the surprise question (would you be surprised if this patient survived another year?), which was the most widely studied. Despite the difficulties, screening is still necessary, and the use of the surprise question appears reasonable.

Finally, apart from the need for ED staff to identify patients with PC needs, interventions to address these issues are complex and require interdisciplinary cooperation and coordination. A systematic review of ED-based PC interventions found compelling, albeit inconsistent, evidence for reduced hospital length of stay, which was likely the result of early palliative consultations allowing for early decisions on GOC, expedited referrals, and streamlined patient throughput (11). This evidence synthesis suggested that ED-based PC interventions have limited impact on mortality, hospitalization, or subsequent healthcare utilization; however, infrequent and incomplete reporting of these important clinical outcomes was documented and additional research on the effect of PC interventions delivered in the ED was strongly recommended (11). Consequently, additional research was necessary to resolve this important question.

The current study

Grudzen et al. should be commended for developing and implementing a multicomponent intervention to initiate PC referrals in the ED (12). The aim of the study was to determine if an educational intervention delivered to emergency staff could improve PC referrals for patients with PC needs. The study was a multicenter, cluster-randomized, stepped-wedge, clinical trial involving 29 EDs in the USA and reported on important outcomes for patients, their families, clinicians and administrators. The target ED population included older adults (>65 years of age) with serious, life-limiting illnesses defined by administrative data and provided as a prompt to the clinicians in their electronic medical record/tracking system. The multicomponent educational intervention was implemented in the EDs over a 3-week intervention period. Clinicians (e.g., emergency physicians, physician assistants, and nurse practitioners) completed a 4-hour in-person or online simulation workshop focused on communication skills, as well as a 1-hour online didactic course on primary PC. Emergency nurses received a 1-hour supplemental course on PC. Clinical decision support tools and audit/performance feedback was provided to clinicians over the course of the intervention. Continuing education credits and nominal gift cards were offered as “incentives”. Impressively, the compliance with course completion was high for the simulation workshop (86%), as well as the 1-hour education sessions for clinicians (87%) and nurses (82%).

The time period and patient volumes were sufficient to detect small differences between the pre- and post-periods. For the primary outcome, hospital admission among this group was high; however, the difference between the periods was not significant {absolute difference, −3.1% [95% confidence interval (CI): −3.7% to −2.5%]; adjusted odds ratio (aOR), 1.03 (95% CI, 0.93–1.14)}. No significant differences in the secondary outcomes of interest including mortality [aOR, 1.07 (95% CI: 0.98–1.18)] and various measures of subsequent healthcare use including admission to the intensive care unit (ICU) [aOR, 0.98 (95% CI, 0.83–1.15)], ≥1 revisit to the ED [aOR, 1.00 (95% CI, 0.91–1.09)], hospice use [aOR, 1.04 (95% CI, 0.93–1.16)] and home health use [aOR, 1.01 (95% CI, 0.92–1.10)]. One might wonder, given the comprehensive nature of the intervention and the high compliance with uptake, why wasn’t this educational intervention effective? There are a variety of possible explanations.

First, the intervention was delivered largely during the COVID-19 pandemic, where services were limited, staffing was more transient, and trainees were not included. This may have diluted the effect of the intervention. Second, there is no way of knowing if the ED clinicians detected the PC needs of the ED patients. As mentioned above, the identification of patients with end-of-life conditions in need of PC referral remains a complex task. In this case, even with training, it’s unclear how often the patients with end-of-life conditions were recognized by the clinical staff. Third, while the intervention was widely disseminated, it was designed to be delivered in the chaotic ED environment, where time pressures, a lack of privacy, and interruptions are all common. Fourth, the intervention was largely directed at ED clinicians and ignored the roles of other providers in the patient’s transitions in care (e.g., social workers, consultants, primary care providers). This isn’t the typical ED approach, where teamwork and collaboration are essential to achieving the best patient outcomes. Finally, patients with end-of-life conditions have high needs and often require admission to the hospital; this decision may have very little to do with the presence or absence of PC referral options. Perhaps an intermediate outcome of quality of life or satisfaction with care would provide more insight.

The future

Despite these rather disappointing results, efforts to address these patients and their needs should not be abandoned. What is clear is that additional research is urgently needed in several areas. First, the optimal timing and most efficient clinical settings for initiating PC referrals need to be further examined. Since nearly two out of three patients with end-of-life presentations required admission on the index ED visit (12), exploring early referral to PC referral from the inpatient setting or for repeat ED visitors may be a more effective strategy. Second, the one-size-fits-all approach may have limited effectiveness. Since the number of patients with end-of-life conditions and PC needs will vary among ED settings, the possible solutions will vary among these institutions. In addition, the various conditions resulting in ED presentation need to be better understood and perhaps even form the basis of specific interventions. For example, in some institutions, patients with cancer represent the most common end-of-life condition, and unmet PC needs in this group could form the basis of a collaborative intervention with primary care providers and specialists caring for these complex patients. Third, while slow, change is occurring, in some cases stimulated by the COVID-19 pandemic. For example, more long-term care facilities are proactively discussing advance directives and GOC with patients and their families prior to their need in a crisis situation (13-15). Fourth, repeat presentations to the ED for patients with unmet PC needs are common. In fact, in this trial, one in three recorded at least one ED revisit and two in five were readmitted (12). Using artificial intelligence technology, ED patients with frequent ED visits for common end-of-life conditions (e.g., cancer, pulmonary disease, dementia) could be identified for review/intervention. Finally, rather than expect clinicians with the least familiarity with a patient/family and likely the least time to deliver PC, collaborative and interdisciplinary approaches are needed. For example, virtual care has been increasingly used to address the needs of patients since the start of the pandemic (16). Perhaps an innovative strategy delivered following the resolution of the acute crisis and post-ED visit could be explored.

Conclusions

For the foreseeable future, the modern ED will increasingly be faced with overcrowding as well as patients with end-of-life conditions and unmet PC needs. The ED is often the last resort for patients and their families in need, often seeking symptom relief and control, management of intercurrent illnesses, and compassionate, non-judgmental care. Clinicians working in these environments take this responsibility seriously, and increasingly, ED physicians are receiving supplemental training and credentialing in hospice and PC. The pressing issue is to explore innovative interventions to improve the end-of-life and PC as part of the quadruple aim (e.g., improving the health of populations, the patient and caregiver experience, provider experiences, in an efficient manner), and to ensure all who need PC receive it, regardless of race (17), sex/gender, religion, and location of residence.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-23/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-23/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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