Palliative care initiated in the ED associated with improved quality of life
A palliative care consultation initiated in the emergency department (ED) for patients with advanced cancer was associated with improved quality of life and did not seem to shorten survival, according to an article published online by JAMA Oncology.
Visits to the ED are common for patients with advanced cancer and it is during these visits that decisions are often made about the intensity of care. Although the availability of palliative care services continues to increase, consultation typically does not happen until a week into a patient's hospital stay. A consultation initiated from the ED may be an opportunity to ensure that care is congruent with a patient's wishes and to interrupt the cascade of intensive, end-of-life care that may be a marker of low-quality care.
Corita R. Grudzen, M.D., M.S.H.S., of New York University, and coauthors conducted a randomized clinical trial to compare quality of life, depression, health care utilization and survival in ED patients with advanced cancer randomly assigned to an intervention with an ED-initiated palliative care consultation vs. usual care.
The study included 136 patients: 69 in the palliative care consultation intervention and 67 in usual care, who also may have received a palliative care consultation if it was requested by the admitting team or an oncologist. Among the 69 patients in the intervention, 41 died by the one-year mark, as did 44 of the 67 patients who received usual care.
The authors report that the palliative care consultation intervention was associated with increased quality-of-life scores from study enrollment to week 12 (average increase of 5.91 points in the intervention vs an increase of 1.08 in the usual care group).
Median survival was longer for patients in the intervention (289 days) compared with the usual care group (132 days), although the difference was not statistically significant. The lack of statistical significance was due to the highly variable length of survival in the study group, the authors note.
The authors found no statistically significant differences in depression, admission to the intensive care unit and discharge to hospice. The authors suggest the impact of palliative care on health care utilization was "more nuanced" in their study.
"Emergency department-initiated palliative care consultation improved QOL [quality of life] in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study," the study concludes.
In a related editor's note, Charles R. Thomas Jr., M.D., a JAMA Oncology deputy editor writes: "Future prospective interdisciplinary studies involving the intersection of emergency and/or urgent care, oncology and palliative care practices are necessary to further refine optimal and cost-effective, patient-centered care for patients with cancer and caregivers."
"This study has demonstrated that an ED visit by a patient with advanced cancer can provide a unique opportunity for improved access to palliative care and quality of life. ... Where do we go from here? It is important to define and test criteria for palliative care referral from the ED in daily clinical practices. ... It will also be important to understand the attitudes and adherence of patients when referred to outpatient palliative care from the ED. In view of the findings of this study, this research is much needed and justified," writes Eduardo Bruera, M.D., of the University of Texas MD Anderson Cancer Center, Houston, in a related editorial.
JAMA Oncol. Published online January 14, 2016. DOI: 10.1001/jamaoncol.2015.5321