Health Care Utilization by Patients Whose Care Is Managed by a Primary Palliative Care Clinic

Abstract

Research related to care at the end of life continues to demonstrate the need for improvement. 1 High rates of hospitalizations and emergency department (ED) visits in the last weeks of life are accepted indicators of poor quality end of life care. [2][3][4] Despite the desire to avoid ED visits at the end of life and die outside of an institutional setting, the majority of Americans continue to die in healthcare facilities, often with their symptoms poorly managed. 3,[5][6][7] A lack of primary care providers that are skilled in delivering palliative care, along with the lack of continuity of care, may be contributing to undesired institutional deaths for people at the end of life. 3 Common reasons that palliative care recipients are ultimately admitted to an inpatient setting include poor pain control, poor symptom management, an unexpected change in physical condition, and overall caregiver burden. 8,9 Another contributing factor to hospital admissions can be the general practitioners limited experience in caring for patients dying at home, as well as their limited experience in the use of opioids and psychiatric medications in the setting of a life-limiting illness. 9 Patients with life limiting illness are not uncommon in the ED. Several studies have investigated ED utilization among patients enrolled in palliative care programs and have reported ranges of 27% 3,10 up to 39% 2,11 of patients utilizing the ED near the end of life. In another study, it was noted that elders who died in the ED demonstrated a considerable palliative care need, though the majority of these patients were referred for palliative care services. 12 Researchers identified several determinants of ED use among their palliative care population including excessive weight loss, a previous hospitalization, 2 women residing in rural areas, having a parent or other relative other than a spouse or child as the primary caregiver, 3 pain, and appetite disturbance. 13 EDs tend to be high stress, fast paced environments with a focus on treatment of acute and traumatic events, 14 and are not the ideal place to treat palliative care patients or those nearing the end of life. 13,14 For example, privacy in the ED is limited, staff members are often not familiar with patients, nor are they necessarily trained to deal with many issues associated with the end of life. 14 Further, patients and their caregivers experience high levels of anxiety and uncertainty when accessing the ED.Correspondence: Alana Murphy, DNP, ARNP, Palliative Care Service, Harborview Medical Center, 325 Ninth Ave, Box 259734, Seattle, WA 98104, anala@uw The primary palliative care practice model differs from an outpatient consultative model in that it seeks to integrate palliative care into primary care. This ensures that palliative needs of patients are routinely addressed in a comprehensive visit from one provider, which also improves continuity of care. The benefits of continuity of care include increased patient and family satisfaction with end-of-life care, reduced ED utilizat...