Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

Abstract

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more "palliative care triggers" on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

Factors Predicting Bereaved Caregiver Perception of Quality of Care in the Final Week of Life: Implications for Health Care Providers

“…Such measures might include standardized team-family meetings to clarify goals of care, development of triggers for palliative care consultation, adherence to established professional EOL care guidelines, proactive consultation of clinical social workers and chaplains, and promotion of generalist palliative care competencies across all disciplines. [58][59][60][61][62] For patients who cannot leave the hospital, teams should be identifying ways to make inhospital care feel more peaceful and dignified (e.g., 24-hour family access, private hospital rooms) and developing policies to ensure high-quality EOL care in the acute care setting (e.g., protocols for ventilator withdrawal and palliative sedation).…”

A Review of Barriers to Utilization of the Medicare Hospice Benefits in Urban Populations and Strategies for Enhanced Access

“…The enhanced availability of home hospice and palliative homecare services may account for these patients ability to die in their place of residence. 28,31 The development of hospice contracts with many local longterm-care facilities has permitted terminally ill older adults who require more care than can be provided in the home-care setting with access to an additional tier of services in nursing homes that may also account for some reduced utilization of the acute-care setting by such patients.…”

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

“…All ED PC referral or integration projects that we examined had some measure of success in terms of increasing PC evaluation and referral from the ED. [69][70][71][72][73] Common weaknesses of prior efforts included absence of evidenced-based development of an ED-specific screening tool, narrow inclusion criteria (i.e., cancer patients only), use of lengthy PC patient assessment tools, and reliance on additional staff to perform screening.…”