Data from emergency medicine palliative care access (EMPallA): a randomized controlled trial comparing the effectiveness of specialty outpatient versus telephonic palliative care of older adults with advanced illness presenting to the emergency department

Abstract

Background The Emergency Medicine Palliative Care Access (EMPallA) trial is a large, multicenter, parallel, two-arm randomized controlled trial in emergency department (ED) patients comparing two models of palliative care: nurse-led telephonic case management and specialty, outpatient palliative care. This report aims to: 1) report baseline demographic and quality of life (QOL) data for the EMPallA cohort, 2) identify the association between illness type and baseline QOL while controlling for other factors, and 3) explore baseline relationships between illness type, symptom burden, and loneliness. Methods Patients aged 50+ years with advanced cancer (metastatic solid tumor) or end-stage organ failure (New York Heart Association Class III or IV heart failure, end stage renal disease with glomerular filtration rate < 15 mL/min/m2, or Global Initiative for Chronic Obstructive Lung Disease Stage III, IV, or oxygen-dependent chronic obstructive pulmonary disease defined as FEV1 < 50%) are eligible for enrollment. Baseline data includes self-reported demographics, QOL measured by the Functional Assessment of Cancer Therapy-General (FACT-G), loneliness measured by the Three-Item UCLA Loneliness Scale, and symptom burden measured by the Edmonton Revised Symptom Assessment Scale. Descriptive statistics were used to analyze demographic variables, a linear regression model measured the importance of illness type in predicting QOL, and chi-square tests of independence were used to quantify relationships between illness type, symptom burden, and loneliness. Results Between April 2018 and April 3, 2020, 500 patients were enrolled. On average, end-stage organ failure patients had lower QOL as measured by the FACT-G scale than cancer patients with an estimated difference of 9.6 points (95% CI: 5.9, 13.3), and patients with multiple conditions had a further reduction of 7.4 points (95% CI: 2.4, 12.5), when adjusting for age, education level, race, sex, immigrant status, presence of a caregiver, and hospital setting. Symptom burden and loneliness were greater in end-stage organ failure than in cancer. Conclusions The EMPallA trial is enrolling a diverse sample of ED patients. Differences by illness type in QOL, symptom burden, and loneliness demonstrate how distinct disease trajectories manifest in the ED. Trial registration Clinicaltrials.gov identifier: NCT03325985. Registered October 30, 2017.

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

“…These observations highlight the opportunity and importance of ED‐based end‐of‐life screening. Significant efforts are being made to advance the science of ED based end‐of‐life care through the development of conversation and decision aids as well as trials of ED‐based palliative care 2,42–44 . If validated, the work described here presents a pragmatic approach to initiate interventions with at‐risk patient populations in a resource‐sensitive manner.…”

Loneliness at end‐of‐life: A scoping review

“…Assessment tools used by included studies included 3‐item UCLA loneliness scale (Abedini et al, 2020; Finkelstein et al, 2021; Schmucker et al, 2021), 20‐item UCLA loneliness scale (Çıracı et al, 2016; Guo et al, 2017), 6‐item De Jong Gierveld loneliness scale (DJGLS) (Walshe et al, 2016), an item from Minimum Data Set for Home Care (MDS‐HC) (Chan et al, 2014), items from the Resident Assessment Instrument for Home Care (RAI‐HC) (Fernandes et al, 2018), the loneliness questionnaire (Rokach et al, 2007a, 2007b), an item from the Hospice Quality of Life Index (Scott et al, 2014), and HIV symptom list (Shawn et al, 2005). Assessment tools measuring loneliness advanced from a single‐item question to assessment tools composed of constructs.…”

“…HIV infections with no access to antiretroviral therapy and were receiving palliative care (mean age = 32)(Shawn et al, 2005), 45.9% among dying cancer patients (mean age = 62) in Israel(Rokach et al, 2007a(Rokach et al, , 2007b, and 10%-34% among adults aged 50 or above with/without cancer or end-stage organ failure in U.S.(Abedini et al, 2020;Schmucker et al, 2021). All the studies, except the cohort study byAbedini et al (2020), were cross-sectional studies.…”

Nurse-Led Telephonic Palliative Care

“…This program is part of the Emergency Medicine Palliative Care Access, [24][25][26][27] a large comparative effectiveness trial funded by the Patient-Centered Outcomes Research Institute comparing facilitated, outpatient specialty palliative care with nurse-led telephonic case management after an ED visit. The study enrolls patients at 18 sites in 9 states.…”