For Dying Patients, Emergency Care Is Less than Ideal

May 2010, Vol 1, No 1

A Canadian study examining the reasons why a patient with cancer will visit the emergency department near the end of life points out shortcomings in current care delivery systems and suggests a greater role for more effective palliative care, say the authors.

The study, a retrospective examination of data from the Ontario Cancer Registry, identified all patients who died of cancer between 2002 and 2005 using ICD-9 codes and examined how often and why they visited the emergency department. The authors, led by Lisa Barbera, MD, MPA, recorded this usage in the final 6 months and final 2 weeks of life.

In this 4-year period in Ontario, 91561 patients died of cancer and were included in the analysis. In the last 6 months of life, 76759 patients made 194017 visits to the emergency department; during the last 2 weeks of life, 31076 patients made 36600 visits. The top 10 reasons in each time period are listed in the Table.

Given the reasons for these visits, the authors argue that “with comprehensive and coordinated palliative care, individual patients could be managed in clinics, at home, and in palliative care units or residential hospices without the need for a visit to the emergency department. A highquality palliative care team would reasonably be expected to be able to address symptoms such as pain, dyspnea, nausea and vomiting, constipation, malaise, and fatigue.”

But building that high-quality team is not easy. Deborah Dudgeon, MD, the provincial head of Palliative Care for Cancer Care Ontario and a coauthor on the paper, detailed some of those obstacles in a follow-up e-mail interview. Geography (with pockets of expert palliative care scattered across the province and inaccessible to more remote regions), the palliative care education of physicians and nurses providing primary care, a lack of physician home visits, and limited home care resources are all factors working against good home-based palliative care.

The Ontario government has worked to address these shortcomings by providing significant funding ($115.5 million US over 3 years) to an end-of-life care strategy beginning in 2005. The funding was directed at enhancing home care services, strengthening volunteer hospice services, funding residential hospices, and planning and integrating local services through regional networks. Dr Dudgeon’s own organization, Cancer Care Ontario, has developed a palliative care program whose strategy includes developing, implementing, and disseminating evidence-based guidelines and standards; the development of a care model for the delivery of palliative cancer care; supporting regional physician leaders; implementing common assessment tools including the Edmonton Symptom Assessment System and Palliative Performance Scale; and developing and measuring quality indicators. Because there is a delay in getting date of death data, the results of these measures (including emergency department visits, length of stay, and place of death) should be evaluable when that data becomes available, Dr Dudgeon indicated.

Systemic Differences, Similar Problems

Eduardo Bruera, MD, F.T. McGraw chair in the treatment of cancer and medical director, Supportive Care Center at M. D. Anderson Cancer Center, noted some of these same issues when discussing the study with Value-Based Cancer Care. Some areas of Canada have excellent home care and community-based programs, he indicated, while others are not as good, so the lack of regionally analyzed data is a shortcoming. Differences in the basic organization of the Canadian system are also an issue, he said.

“The healthcare system in Canada is dramatically different from that in the United States,” Dr Bruera emphasized. “Patients can go to the emergency center and be admitted without any fear of a financial consequence from doing it. We need to remember that even Medicare patients in the United States still pay a substantial proportion of their cost of emergency and inpatient care. In Canada, the cost is pretty well zero.”

This may have pushed the number of patients availing themselves of the emergency department higher, he suggested.

Nevertheless, “overwhelmingly this is an excellent study…truly a population-based study,” he enthused. Be cause of the structure of the Canadian healthcare system, there are no biases due to age or insurance type, Dr Bruera pointed out, and “that’s what makes it dramatically useful for us to understand [the] experience of cancer patients.”

The structure of the US healthcare system introduces its own impediments to good palliative care, Dr Bruera suggested. First among them is the conception of palliative care itself by hospitals and cancer centers. Too often, palliative care is initiated too late in the trajectory of illness.

By “limiting palliative care programs to the inpatient [setting], the catastrophic event that brought the patient to the emergency room and gotten them admitted has already occurred,” he argued.

A second barrier involves paying for treatment. The Medicare hospice benefit is currently structured so that patients who enter into hospice care are not eligible for continued cancer treatment. So if the patient and the family want to continue receiving cancer treatment, Dr Bruera explained, they will delay access to hospice or the oncologist will delay referral to hospice until the cancer

treatment has been completed. And with the rise of targeted therapies, which are generally better tolerated than traditional chemotherapies, treatment can continue longer into the course of illness.

“At this point, it’s an either/or system, in which a patient enters the Medicare hospice benefit, and therefore exits the traditional reimbursement system in the United States,” he said.

Dr Bruera foresees “great opportunities to develop palliative care programs in acute care facilities, in teaching hospitals, and in cancer centers that operate according to the existing reimbursement mechanisms,” suggesting that these centers can do an outstanding job in providing in- and outpatients with integrated cancer treatment and supportive and palliative care. Data from the Canadian study may serve to foster the development of palliative care programs in the acute care setting, Dr Bruera argued.

It will also be essential to develop a real integration of hospice care with acute care, rather than making it one or the other, Dr Bruera emphasized.

“This would allow patients who are interested to access hospice care at home a little bit earlier, while they are still receiving cancer treatment,” he pointed out. “Accessing both systems might allow patients to avoid unnecessary emergency room [visits] and hospitalizations. While this looks like a more expensive [way to go], it might…prove to be beneficial financially.”

M. D. Anderson has taken this integrated care approach for almost 11 years, Dr Bruera stated, and he pointed out that a number of other centers around the nation, including the cancer center in San Diego and the Cleveland Clinic, have also incorporated this approach.

Care Setting Makes Psychic, Financial Difference

The question of where care is provided also raises the matter of value. If the intention is to keep patients receiving very complex therapy as is given in the acute care facility, but to transition those people to the community, then there’s a high risk of failure and enormous distress for the patient and the family, Dr Bruera stated. A third-party payer may want the patient in the community, Dr Bruera said, but it may not take into consideration the enormous physical and emotional burden they are putting on that patient’s relatives in the process of doing that. This creates a major ethical dilemma for caregivers.

“What is the advantage of having that person with this extremely complex therapy staying at home?” Dr Bruera wondered. “If we transfer care to the community, then we would see what the Canadian paper shows—patients with extremely complex interventions coming back to the emergency department and getting admitted.”

As the authors of the Canadian study emphasize, “Patients who are failing at home are unlikely to need to visit the emergency department. Instead, these patients require either additional support to remain at home or direct transfer to a palliative care unit or residential hospice.”

Dr Bruera built on this notion, arguing that for care in the community to be successful over time, it is important to pay attention to care transitions. “We need to simplify a lot of the interventions that [are] being administered as part of the acute care of the patient.” Home care, Dr Bruera emphasized, puts an enormous burden on the patient’s family. “We can keep very simple treatments in the community.”

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