Ill, Older Patients Who Rely on Emergency Room Often Live Final Days in Hospital, Study Finds

Hospice Care Would Improve Quality of Life and Lower Costs, Say Authors

Half of adults over age 65 made at least one emergency department (ED) visit in the last month of life, in a study led by a physician at the San Francisco VA Medical Center (SFVAMC) and UCSF.

Three quarters of ED visits led to hospital admissions, and more than two-thirds of those admitted to the hospital died there.

In contrast, the 10 percent of study subjects who had enrolled in hospice care at least one month before death were much less likely to have made an ED visit or died in the hospital.

“For too many older Americans, the emergency department is a conduit to hospital admission and death in the hospital,” said lead author Alexander K. Smith, MD, MS, MPH, a palliative medicine doctor at SFVAMC and an assistant professor of medicine in the Division of Geriatrics at UCSF.

The study, published in the June issue of Health Affairs, was based on an analysis of health records of 4,518 people age 65 and older who died while enrolled in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement and aging sponsored by the National Institute on Aging.

“Unfortunately, the emergency department is not an ideal setting for patients nearing the end of life,” observed Smith. “Aside from the fact that most patients prefer to die at home, ED visits can be incredibly expensive for patients and families, and contribute significantly to the high costs of care at the end of life.”

In addition, he noted, “the traditional focus of the ED is stabilization and triage, not end-of-life care, while hospice provides care specifically for patients with a prognosis of six months of life or less.”

Smith explained that hospice care, which is free to everyone enrolled in Medicare, is centered on the treatment and relief of symptoms that are common near the end of life, such as pain, nausea, shortness of breath and confusion. “These are quite often the symptoms that lead patients who are not in hospice care to visit the ED,” he said.

The majority of hospice care is provided in the patient’s home.

“The interdisciplinary hospice care team is very skilled at providing relief from other forms of suffering as well, such as spiritual and psychological pain,” said Smith. “They also provide bereavement support for families before and after death.”

To encourage timely enrollment in hospice care, the study authors recommended that governments, health care systems and insurers institute policies that encourage physicians to discuss end-of-life care with patients and their families, including reimbursement for advance care planning.

Smith also noted that even if more patients and families make earlier preparations for end-of-life care, “some patients will still end up in the emergency department near the end of life.” To cope with that eventuality, he said, “we need to encourage policies that will make the ED a place where patients can receive the kind of care they need, such as better care of pain, nausea and other symptoms.” He suggested that a “palliative care pathway” could be created to meet the needs of patients who go to the ED seeking relief from suffering.

Co-authors of the study are Ellen P. McCarthy, PhD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA; Ellen Weber, MD, of UCSF; Irena Stijacic Cenzer, MA, and W. John Boscardin, PhD, of SFVAMC and UCSF; Jonathan Fisher, MD, MPH, of Harvard Medical School and BIDMC; and Kenneth E. Covinsky, MD, MPH, of SFVAMC and UCSF.

The study was supported by funds from the National Palliative Care Research Center, the National Center for Research Resources UCSF-Clinical and Translational Science Institute (CTSI) and the National Institute on Aging, some of which were administered by the Northern California Institute for Research and Education.

NCIRE — The Veterans Health Research Institute — is the largest research institute associated with a VA medical center. Its mission is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

End-of-Life Communication

What is the best way to talk to someone about prognosis and quality of life when serious illness strikes? It turns out that no one had studied that question through direct observation, until the University of Rochester Medical Center audio-recorded 71 palliative care discussions.

The data is published online in the Journal of Pain and Symptom Management.

Lead author Robert E. Gramling, M.D., Sc.D., associate professor of Family Medicine at URMC, and colleagues with a special interest in palliative care, made several key discoveries:

-- In 93 percent of the conversations, prognosis was brought up and discussed by at least one person, with the palliative care team broaching the issue 65 percent of the time. Also, the prognosis information focused more often on quality of life rather than survival, and on the unique individual rather than the population in general. Researchers noted that prior studies support the link between open and honest discussions about prognosis to clinical benefits.

-- Both patients/families and physicians/nurses on the palliative care team tended to frame prognosis with more pessimism than optimism. This was unexpected and different than the usual patterns of communication, where talk of a serious illness tends toward avoidance or unbalanced optimism, researchers said. However, emphasizing accuracy during the palliative care consultation usually leads to treatment decisions that match patient preferences.

-- The substance and tone of the conversations varied, depending on whether the patient was present and actively participating. For example, prognosis conversations with family members alone were more pessimistic and contained more explicit information. It is possible, researchers said, this type of conversation takes place out of respect for the patient, who might be sicker in this scenario, or is someone who prefers to avoid information.

-- The closer to death, the more likely the palliative care physician was to foretell or forecast events. This might seem logical – that doctors would guide patients and families in what to expect as death approached – but in reality this vulnerable and frightening time is when families often report a void in communication. The URMC data suggests that palliative care consultations respond to this need.

“Good communication might be the single most important element of palliative care,” Gramling said, “and through direct observation we have demonstrated how these talks occur and the important dimension they add at the end of life.”

The study took place at Strong Memorial Hospital at URMC, which has an in-patient hospice unit and provides more than 1,000 palliative care consultations annually at the hospital. With prior consent from all study participants, researchers placed high-definition digital recorders in unobtrusive locations in hospital rooms before the prognosis discussions took place.

Afterward, researchers coded the conversations based on whom was speaking, the topic, and how the information was framed, and then analyzed the data.

Examples of statements coded for prognosis: “It is unlikely that you will live for more than a month.”Also -- “I believe that your breathing will continue to worsen, and we need to prepare for that.”

An example of statements coded for length of life: “I expect that you will live for days to weeks, rather than months to years. About 30 percent of people live for a month or more.”

An optimistic framing statement: “The good news is I expect you will live for a few more months. | I believe your chances of surviving up to six months are quite good.”

An example of a statement coded for quality of life: “But you know you never know. Sometimes people perk up for awhile. And it may be with a little extra blood you'll perk up for awhile and we'll all enjoy it if you do.”

Providing a palliative care consultation has become much more complex in recent years. As the demand for these services has risen, so has the breadth of services. No longer is palliative care an either-or proposition – either relieving suffering or treating the illness medically. It has evolved into a combination of the two, along with opening communication with the patient and family so they know what to expect.

“When patients and families clearly understand the road ahead they can make the best decisions, based on their own values, desires, and goals,” Gramling added. “Without correctly framing the facts, however, discussions can become unbalanced or lack the context to be helpful.”

The National Palliative Care Research Center and the Greenwall Foundation funded the study. Rochester co-authors include Sally A. Norton, Ph.D., RN; Maureen Metzger, M.S., R.N., and Jane DeLuca, Ph.D., R.N., all of the UR School of Nursing; Susan Ladwig, M.P.H., and Daniel Schatz, of the UR School of Medicine and Dentistry; Ronald Epstein, M.D., professor of Family Medicine. Psychiatry, Oncology and Nursing at URMC; and Timothy Quill, M.D., professor of Medicine, Psychiatry, and Medical Humanities, and director of the Center for Ethics, Humanities, and Palliative Care at URMC. David Gramling, Ph.D., of the University of Arizona, and Stewart Alexander, Ph.D., of Duke University, also contributed to the study.