Quick Safety 66: Palliative care: Better care for seriously ill patients visiting the ED

Issue:

Patients who are seriously ill often turn to, or are inappropriately admitted to, already overburdened emergency departments (EDs) for care that may be better addressed by palliative care services.

Hospice care falls under the umbrella of palliative care services. The difference is that patients qualify for hospice care when they have a life expectancy of six months or less; palliative care can be provided “at any stage in a serious illness and is beneficial when provided along with treatments of curative or life-prolonging intent.”¹ Furthermore, palliative care:

• Provides symptom management, offers caregiver support, and coordinates the provision of care across settings.
• Is a person- and family-centered approach to care that provides seriously ill people with relief from the symptoms and stress of an illness.
• Attends to the physical, functional, psychological, practical, and spiritual aspects of a serious illness.
• Is inclusive of all people with serious illness, regardless of setting, diagnosis, prognosis, or age.
• Can be provided over time to patients based on their needs and not their prognosis.
• Can be offered in all care settings and by various organizations, such as doctors’ offices, health systems, cancer centers, dialysis units, home health agencies, hospices, and long-term care providers.

 

While not new to healthcare, palliative care is slowly being recognized as a beneficial and necessary service for the seriously ill, including children. According to a survey conducted by the National Hospice and Palliative Care Organization (NHPCO) over 85,000 seriously ill individuals received palliative care services in 2017 through its members, representing palliative care service providers in 48 states.²

 

Reasons to utilize palliative care

In addition to contributing to the workload of EDs, seriously ill patients may be unnecessarily hospitalized, potentially exposing them to adverse events that come with hospitalization, such as healthcare-associated infections, as well as physical or psychological trauma resulting from the admission. A longitudinal study of older adults in the period 1992-2006 found that 51% of 4,158 decedents visited the ED in the last month of life. Of those patients seen in the ED in the last month of life 77% were admitted to the hospital, and 68% of those who were admitted died there.³

The National Coalition for Hospice and Palliative Care Clinical Guidelines for Quality Palliative Care, 4th Edition, provides the following rationale for utilizing palliative care:

• Patients of all ages, living in all areas of the country, have unmet care needs that cause a burden on families and the U.S. healthcare system.¹
• Providing “crisis-care” to individuals with a serious illness whose ongoing care needs are poorly managed has resulted in increased healthcare spending that does not necessarily improve quality of life.¹
• Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family.¹

Ideally, palliative care is discussed with patients at the time of diagnosis of advanced heart disease, dementia, cancer, or other serious conditions and can be delivered concurrently with life-prolonging care.³

 

Safety actions to consider:

Hospitals can take the following actions to help address the needs of seriously ill patients and provide them with the best possible quality and safe care in a timely manner by considering early referral or provision of palliative care services.³

• Examine trends in ED usage as well as hospital admissions to determine if appropriate palliative care services could benefit patients.
• Consider collaborating with local organizations that have a palliative care program or provide palliative care services or have palliative care expertise.
• Provide palliative care education to all staff caring for seriously ill patients.
• Support efforts in the ED to incorporate palliative care principles into their practices.³
  
  

Resources:

1. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, Virginia: National Coalition for Hospice and Palliative Care; 2018.
2. National Hospice and Palliative Care Organization. NHPCO Palliative Care Needs Survey Results, 2018. NHPCO, Alexandria, Virginia.
3. AK Smith, E McCarthy, E Weber, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Affairs, 2012;31(6):1277-1285.
   
   

Additional resources:

• Get Palliative Care – Resources include how to find a provider.
• Standards of Practice for Pediatric Palliative Care: Professional Development and Resource Series – National Hospice and Palliative Care Organization. Alexandria, Virginia. For more information and to order: https://www.nhpco.org/palliativecare/pediatrics/pediatrics-professional-resources/

Note: This is not an all-inclusive list.