Barriers to Recruiting ED Patients With Advanced Cancer for Palliative Care

Patient refusal, symptom burden, and diagnostic disparities were identified as some of the most common barriers encountered when recruiting patients with advanced cancer for palliative treatment in the emergency department (ED).

Several factors regarding the ED setting can preclude use of palliative care services, including the fact that patients and families that check into an ED usually do so because they are highly stressed. Recruiting advanced cancer patients in this setting may be important, considering that vital decisions on intensity of care or using life-prolonging treatment may be made in these patients.

In this prospective study, published in The Journal of Community and Supportive Oncology, authors recruited patients who presented at the ED of the study hospital over an 18-month period starting June 2011. Eligibility criteria included:

• A known metastatic solid tumor
• No previous palliative care consult
• The ability to speak English or Spanish
• A score ≥4 on the 6-Item Screener for cognitive impairment

Prior to research staff inviting the patients to enroll on the study, approval from the ED attending was required and the patient’s medical oncologist had to agree. Patients were offered a $20 incentive to participate in the study.

The authors could only enroll 73 patients, instead of the target 150 (49% enrollment rate)—77 patients did not participate because of the following barriers:

• Patient refusal, documented in 38 patients (49%). Most common reasons included no interest in participating, satisfaction with current care, or not ready for palliative care.
• Diagnostic disparity regarding stage of disease, documented in 11 patients (14%).
• Symptom burden was documented in 9 patients (12%); these included dyspnea, pain, and sedation after analgesic administration.
• Family refusal was responsible for 7 patients (9%) left out of trial enrollment.
• Physician refusal in 7 patients (9%) also prevented enrollment, with reasons including patient not ready for palliative care or confusion over inclusion criteria.
• Inadequate knowledge about cancer or stage.

The authors conclude that the barriers they noted mirror those observed with palliative care enrollment in other healthcare settings. These previous studies, the authors note, recommend using adaptive approaches for recruitment, including:

• Integrating screening questions into clinical services
• Tailoring research information for each patient
• Increased collaboration between research and clinical teams

The authors of the current study propose the development of specific strategies to overcome physician and family barriers, training non-clinical staff to overcome ED-specific recruitment obstacles, and broadening trial inclusion criteria as a way forward.