Background

Patients with end of life care needs frequently present to emergency departments (EDs) throughout the world, whether for life sustaining treatments, symptomatic relief or social needs.Previous research has demonstrated that these patients and their families often do not have their expectations of care met by the ED, and furthermore, may even experience greater suffering. Emergency medicine (EM) physicians and nurses may not be adequately trained to deal with this specific patient population, and it may be helpful to develop policies and teaching models to address this. The ED can determine the entire trajectory of one’s care in the hospital, and an ED visit can be an important opportunity to establish goals of care and prioritize a patient’s comfort. In this article, the authors establish a model for palliative and hospice care in the ED and evaluate its efficacy.

Clinical Question

Does a novel hospice and palliative care initiative increase utilization of palliative care services and increase the ability of ED nurses to provide care to this patient population?

Population

Patients presenting to Chi-Mei Medical Center Emergency Department in Taiwan. This is a tertiary care hospital with 1276 inpatient beds. The emergency department is staffed with board certified emergency physicians and sees an average of 145,000 patients per year.

Intervention

Early Phase: All ED physicians and nurses were encouraged and funded to receive training for hospice and palliative medicine. Every resident of emergency medicine rotated through the hospice ward for 1 month.

Late Phase: Educational programs for hospice and palliative care provided in the ED, interdisciplinary meetings with the hospice team were held every month, a cell phone communication app was provided for sharing information and experiences, and an emergency hospice room for end-of-life patients in the ED was created.

Control

Patients seen prior to intervention phases

Outcomes

1. Number of DNR orders signed in the ED
2. Ratio of DNR orders signed in the ED/total DNR orders signed in the hospital
3. Cases of consultation with hospice team in the ED
4. Ability of ED nurses to provide hospice and palliative care, defined as anonymous yes/no answers to the self-assessments of “know how to perform hospice care” and “know when and how to consult hospice team.”

Design

Retrospective, before and after study

Excluded

Study does not list any exclusion criteria

Primary Results

  • 648 patients had DNR orders signed in the ED during the intervention and post-intervention phases
  • 193 Hospice consults placed while patient was in the ED

Critical Results

Pre Intervention Early Intervention Late Intervention Post Intervention p value
DNR orders signed in ED per month 4.0 30.1 23.9 34.6 < 0.001
Ratio of DNR orders signed in ED/Hospital per month 10.8% 17.0% 12.5% 22.8% >0.05
Cases of palliative/hospice consultation per month 0 0 19 19 <0.001
RN “knows how to perform hospice care” 68.1% – – 95.7% <0.001
RN “knows when and how to consult hospice team.” 57.4% – – 95.7% <0.001

Strengths

  • Study asks an important question
  • Outcomes were measurable
  • Statistically significant results were reported

Limitations

  • Inclusion and exclusion criteria were not specified
  • The pre-intervention time period was not quantified
  • There is no specified primary outcome
  • It is unclear if patients benefited from the intervention. An increase in DNR orders and palliative care consultations does not automatically mean patient care was improved
  • There are no details on the methods of their chart review
  • Some of the interventions were not clearly defined. Specifically, it is unclear how providers were encouraged to seek additional training or what that training was
  • Objective outcomes (DNR orders, consults/month) determined via chart review. Data may have been missed during this review
  • Nurse improvements in skills subjectively measured (no assessment tool)
  • This was a single center pilot study at a large tertiary care center, so general applicability is in question. Results will need external validation

Author's Conclusions

“We successfully implemented a novel model for hospice and palliative care in the ED by a professional leader, including education of ED physicians and nurses, close collaboration with the hospice team, and an isolated space for patients with end-of life, which could be an important reference for other EDs and intensive care unit in the future.”

Our Conclusions

In this single center study, the proposed model appears to increase utilization of end of life care services. However, due to a lack of clarity in the data reporting it is difficult to judge its success. More study and potentially implementation of similar models in other hospital systems is needed.

Potential Impact To Current Practice

Based on the current available data, EM physicians and nurses can benefit from additional palliative care training.

Bottom Line

Providing additional training and resources to EM providers in the area of palliative care and hospice medicine has the potential to increase utilization of these services in the ED.