Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral

Liberman, Tara; Kozikowski, Andrzej; Kwon, Nancy; Emmert, Brian E.; Akerman, Meredith; Pekmezaris, Renée

doi:10.1016/j.jemermed.2017.08.009

Cited by 22 publications

(74 citation statements)

References 26 publications

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“…Liberman et al found significantly higher rates of hospice referral and decreased rates of inpatient admission or discharge to nursing homes/usual residence following an ED-led goals-of-care training intervention. 25 Patients in their study cohort had longer hospital lengths of stay (while waiting for a place at the hospice) and shorter hospice lengths of stay, but this was attributed to a lack of local hospice service availability rather than the discussion itself.…”

Section: Harms and Benefits Of Goals-ofcare Discussion In Edsmentioning

confidence: 91%

“…We found literature regarding the utility of education for clinicians in how to identify patients for goals-ofcare discussions. Liberman et al found that ED doctors could recognise 90% of patients in need of goals-of-care discussions following a training intervention, 25 but this might have been biased because of historical controls and small study size.…”

Section: Identification Of Patients For Goals-of-care Discussion In Edsmentioning

confidence: 99%

“…26 Ideal timing of discussions in EDs was not determined, although two studies found that ED-led conversations took an average of 10 min. 25,28 The ideal discussion facilitator was not identified. Most ED clinicians in a large qualitative study noted that they conducted goals-of-care discussions frequently, felt they were within their scope of practice and were adequately trained.…”

Section: Requirements For Goals-of-care Conversations In Edsmentioning

confidence: 99%

“…Requirements for ED discussions 5 [24][25][26][27][28] Content of ED discussions 1 24 Variations in content for EDs compared with other settings 0 Variations in content for CALD populations 0 Documentation of discussions to meet patient and clinical needs 1 28 Harms and benefits of discussions in EDs 1 25 not involved in its design, and we might have omitted aspects of the topic that would have been important to them. There might also be varied research interpretations of the term 'goals-of-care' given the lack of standardisation in definitions and understanding.…”

Section: Limitationsmentioning

confidence: 99%

See 3 more Smart Citations

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Hanning

Walker

Horrigan

et al. 2019

Emerg Medicine Australasia

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Goals-of-care discussions at end-oflife are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life-expectancy. It is unclear how goals-of-care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals-of-care discussions. We sought primary evidence on goals-of-care discussions in EDs with adult patients nearing end-oflife, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals-of-care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals-of-care conversations in EDs. Increased ED goals-of-care conversations increased hospice referral and reduced in-patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals-of-care' is used inconsistently across the literature. This is the first systematic review regarding goals-of-care discussions in EDs. Further research is needed on all aspects of these conversations.

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Section: Harms and Benefits Of Goals-ofcare Discussion In Edsmentioning

confidence: 91%

Section: Identification Of Patients For Goals-of-care Discussion In Edsmentioning

confidence: 99%

Section: Requirements For Goals-of-care Conversations In Edsmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

See 2 more Smart Citations

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Hanning

Walker

Horrigan

et al. 2019

Emerg Medicine Australasia

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“…La frecuencia de enfermedad en fase terminal en servicios de emergencia es variable y subestimada6; estudios realizados en Norteamérica, Europa y Asia han demostrado que el empleo de cuidados paliativos en pacientes con enfermedades terminales (institucionalizados y seguimiento domiciliario), disminuye admisiones hospitalarias, ingresos a cuidados intensivos y frecuentación a urgencias; sin diferencia significativa en el tiempo de sobrevida de estos pacientes; mejorando mucho las condiciones del paciente y la familia [7][8][9][10][11][12][13][14] . Pero también se reporta alta frecuencia de atención de estos pacientes en emergencia, donde muchos fallecen sin recibir cuidados paliativos 15,16 .…”

Section: Introductionunclassified

Pacientes con enfermedad crónica terminal en el servicio de emergencia de adultos de un hospital terciario

Amado-Tíneo

Taype-Huamaní

Vásquez-Alva

et al. 2019

RFMH

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Introducción: Pacientes con enfermedad crónica terminal acuden con frecuencia a emergencia de hospitales de referencia. Objetivo: Determinar la frecuencia de enfermedad crónica terminal en pacientes admitidos a emergencia, identificar procedimientos invasivos y comparar oncológicos con no oncológicos. Métodos: Estudio de corte transversal, en mayores de 18 años admitidos a emergencia de un hospital terciario, noviembre 2017. Se consideró enfermedad terminal al cáncer en estadio clínico IV, deterioro cognitivo severo o dependencia funcional total más diagnóstico de demencia, secuela neurológica, dependencia de oxígeno, índice de filtración glomerular < 30 ml/min, cirrosis hepática Child C o fracción de eyección ventricular izquierda < 20%. Análisis estadístico con U de Mann-Whitney y Chi cuadrado. Resultados: El 10,7% (172 de 1604 admisiones) de los pacientes admitidos presentaron criterios de enfermedad crónica terminal, de causa oncológica 21,5% (37/172) y no oncológica 78,5% (135/172). En oncológicos la mediana de edad fue 70 años y sexo femenino 59,5%, mientras que en no oncológicos 84 años y 57% de mujeres (p<0,01 y 0,79 respectivamente). El 41% (71/172) ingresó por unidad de shock trauma, con mayor frecuencia por somnolencia y disnea. Se identificó procedimiento invasivo probablemente innecesarios en 21,5% (37/172 pacientes), intubación orotraqueal y catéter venoso central para inotrópicos fueron los más frecuentes. La estancia promedio en emergencia fue ocho días, falleciendo en emergencia 32% de oncológicos y 24% de no oncológicos (p=0,43). Conclusión: El 10% de los pacientes admitidos a emergencia de un hospital terciario presenta enfermedad crónica terminal, con mayor frecuencia no oncológica, realizándose procedimientos probablemente innecesarios en la quinta parte de estos.

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A Hospice Transitions Program for Patients in the Emergency Department

Baugh,

Ouchi,

Bowman

et al. 2024

JAMA Netw Open

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ImportancePatients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care.ObjectiveTo assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life.Design, Setting, and ParticipantsThis pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022.Main Outcome and MeasuresThe primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality.ResultsThis study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P &lt; .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P &lt; .001).Conclusions and RelevanceIn this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

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Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral

Cited by 22 publications

References 26 publications

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Pacientes con enfermedad crónica terminal en el servicio de emergencia de adultos de un hospital terciario

A Hospice Transitions Program for Patients in the Emergency Department

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