Christina Creel-Bulos
Washington University School of Medicine in St. Louis
Dr. Creel is a former registered nurse and current second year Emergency Medicine resident at Washington University in St. Louis, where she additionally serves as an Advanced Cardiac Life Support and Advanced Trauma Life Support instructor and advocate for multidisciplinary teamwork. Her interests include critical care medicine, resuscitation medicine and palliative care.
One in five patients access healthcare at the end of life (EOL), often through the Emergency Department (ED). Despite data demonstrating benefits of early palliative care (PC) interventions at EOL, barriers exist with respect... [ view full abstract ]
One in five patients access healthcare at the end of life (EOL), often through the Emergency Department (ED). Despite data demonstrating benefits of early palliative care (PC) interventions at EOL, barriers exist with respect to ED identification of appropriate patients and subsequent early implementation. Objectives of this study were to evaluate current ED trends in EOL care amongst acutely dying patients and to retrospectively identify the subset of this population that would benefit from early ED PC initiation.
Retrospective descriptive cohort analysis was performed within an urban academic tertiary ED. Institutional record review identified adult patients who expired within 24-hours of presentation to the ED; 307 patients qualified between November 2014 and December 2015. Comorbidities, dispositions, and medical interventions were examined. A validated PC screening tool was then applied; amongst those deemed to benefit from PC, therapeutic management and resource utilization were further reviewed.
Of the 307 patients identified, 76% were ventilated, 63% received vasopressors/inotropes; 54% underwent cardiopulmonary resuscitation, 25% underwent central venous cannulation, and 15% underwent intra-arterial pressure monitoring. ED goals of care (GOC) discussions were documented in 21% of cases.
Amongst 307 patients reviewed, 60% screened positive for application of PC services based on the validated P-CaRES tool. Life-limiting illnesses included advanced: cancer (18%), heart failure (15%), and dementia (14%). A high chance of accelerated death was noted in 41% of cases. Amidst those meeting P-CaRES criteria, 54% died within the ED. Of the admitted patients, 79% went to an ICU. During their admission, 66% were subsequently transitioned to comfort care after an inpatient GOC discussion.
Despite aggressive escalations in ED management and ICU admissions, de-escalation of care upon admission was commonly noted. A need exists for further investigation of factors influencing emergency medicine practices at the EOL and methods to promote early PC/EOL strategies within the ED.
Prevalence and drivers of overuse , Overuse in the care of the elderly and at end of life
