Palliative medicine in the emergency department: symptom control and aggressive care

Abstract

ObjectivesIdentifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care.MethodsWe conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson’s Index.Results384 adults died at the ED (median age 82 (IQR 72–89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2–4) vs 3 (2–5)), p=0.082.ConclusionsNearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.

Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach

“…After reviewing the titles, abstracts and full texts, 212 articles were excluded because they led to another topic, 310 were excluded because they addressed another topic about EOL in ED, 126 were excluded because they addressed another topic about EOL patients outside ED, 12 were excluded because the full text was not available, 8 were excluded because they were not in English, and no article was excluded because it was not conducted in humans. In total, 19 articles were eligible for inclusion, and after removing duplicates, 9 articles were included (Bell, 2018 [ 29 ], Chan, 2021 [ 30 ], Coine, 2021 [ 31 ], de Oliveira, 2021 [ 32 ], Lamba, 2010 [ 33 ], Long, 2020 [ 34 ], Rojas, 2016 [ 35 ], Siegel, 2017 [ 36 ], Solberg, 2015 [ 37 ]) (see Figure 1 for the PRISMA flow diagram for the studies selection process).…”

“…One study was a prospective observational study (Coyne, 2021 [ 31 ]), three were retrospective studies (Chan, 2021 [ 30 ], De Oliveira, 2021 [ 32 ], Rojas, 2016 [ 35 ]) and five were narrative reviews (Bell, 2018 [ 29 ], Lamba, 2010 [ 33 ], Long, 2020 [ 34 ], Siegel, 2017 [ 36 ], Solberg, 2015 [ 37 ]). One study examined the management of geriatric patients at the end of life (Bell, 2018 [ 29 ]), two studies examined oncology patients in palliative care (Coyne, 2021 [ 31 ] and Long, 2020 [ 34 ]), two studies examined patients in hospice or in need of hospice care (Lamba, 2010 [ 33 ], Siegel, 2017 [ 36 ]), and three studies examined end-of-life patients who needed palliative care for any reason (de Oliveira, 2021 [ 32 ], Rojas, 2016 [ 35 ], Solberg, 2015 [ 37 ]). Regarding age, one narrative review (Bell, 2018 [ 29 ]) and four observational studies (Chan, 2021 [ 30 ], Coyne, 2021 [ 31 ], de Oliveira, 2021 [ 32 ], Rojes, 2016 [ 35 ]) focused on adult patients, while three narrative reviews did not include information on the age of the patients studied.…”

“…One study examined the management of geriatric patients at the end of life (Bell, 2018 [ 29 ]), two studies examined oncology patients in palliative care (Coyne, 2021 [ 31 ] and Long, 2020 [ 34 ]), two studies examined patients in hospice or in need of hospice care (Lamba, 2010 [ 33 ], Siegel, 2017 [ 36 ]), and three studies examined end-of-life patients who needed palliative care for any reason (de Oliveira, 2021 [ 32 ], Rojas, 2016 [ 35 ], Solberg, 2015 [ 37 ]). Regarding age, one narrative review (Bell, 2018 [ 29 ]) and four observational studies (Chan, 2021 [ 30 ], Coyne, 2021 [ 31 ], de Oliveira, 2021 [ 32 ], Rojes, 2016 [ 35 ]) focused on adult patients, while three narrative reviews did not include information on the age of the patients studied. See Table 2 for the general characteristics of the included studies.…”

“…Observational studies reported the following: one retrospective study reported the use of opioids in 70.2% of patients (Chan, 2021 [ 31 ]); two studies reported the use of NSAIDs, paracetamol, tramadol, and long- and short-acting opioids (Coyne, 2021 [ 31 ], de Oliveira, 2021 [ 32 ]); and two studies reported the use of only morphine via an intravenous bolus and drip (Lamba, 2010 [ 33 ], Rojas, 2016 [ 35 ]). The included reviews recommended the use of paracetamol, morphine or hydromorphone (Bell, 2018 [ 29 ]); sustained-release and immediate-release morphine with specific dosing for patients already receiving opiate therapy (Lamba, 2010 [ 33 ]); the use of different medications according to pain type (nociceptive, neuropathic or bone pain) (Long, 2020 [ 34 ], Siegel, 2017 [ 36 ]); and the use of non-opioids, weak opioids or strong opioids/weak opioids according to the WHO pain ladder (Siegel, 2017 [ 36 ], Solberg, 2015 [ 37 ]).…”

“…Coyne et al [ 31 ] reported on the percentage of medications used and demonstrated the association between severe pain and the need for hospitalisation, especially in patients requiring opioids and with poor functional status. De Oliveira et al [ 32 ] reported that palliative care needs were not met in 78.4% of patients, and only 56% of patients received medication for pain relief, showing that little attention was paid to palliative care compared to curative care. Rojas et al [ 35 ] demonstrated the benefits of a palliative care protocol by reporting letters of appreciation from relatives.…”