ED-Initiated Palliative Care Can Improve Quality of Life

Despite the fact that visits to the emergency department (ED) are common for patients with advanced cancer, delivery of palliative care is not standard within most EDs. A new study published in JAMA Oncology, suggests that ED-initiated palliative care consultation improved quality of life (QOL) for patients with advanced cancer and does not appear to shorten survival. The impact of ED-initiated palliative care on depression and healthcare utilization is not as clear and deserves further study.

Corita R. Grudzen, MD, MSHS, of New York University, and colleagues conducted the single-blind, randomized clinical trial of ED-initiated palliative care consultation in 136 patients with advanced cancer versus usual care from June 2011 to April 2014 at an urban academic ED at a quaternary care referral center.

“Although the availability of palliative care services continues to increase, consultation typically does not occur until a week into a patient’s hospital stay,” the authors wrote. “Thus, the ED presents a key decision point at which physicians set the subsequent care trajectory during a hospitalization.”

Study subjects were adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by a palliative care provider, and spoke English or Spanish. They were randomized to palliative care consultations intervention (69 patients), and usual care (67 patients). Among the patients in the intervention, 41 died by the 1-year mark, as did 44 of the 67 patients who received usual care.

The palliative care consultation intervention was associated with increased QOL scores from study enrollment to week 12 (average increase of 5.91 points in the intervention group versus an increase of 1.08 in the usual care group). Median survival was longer for patients in the intervention group (289 days) compared with the usual care group (132 days), but the difference was not significant, most likely because of the highly variable length of survival in the study groups.

There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice, and the authors suggest that the impact of palliative care on health care utilization was “more nuanced” in their study.

In a related editor's note, Charles R. Thomas Jr., MD, concluded, “Future prospective interdisciplinary studies involving the intersection of emergency and/or urgent care, oncology and palliative care practices are necessary to further refine optimal and cost-effective, patient-centered care for patients with cancer and caregivers."