Palliative care needs of advanced cancer patients in the emergency department at the end of life 53 BACKGROUND Although cancer has become a chronic disease in many patients, still yearly 8.9 million patients die of widespread disease worldwide, which makes cancer a leading cause of death in developed countries.1 To provide advanced cancer patients with a good quality at the end of life, integration of appropriate palliative care into standard care is essential.2 Palliative care is driven by patients’ care needs and wishes and must be offered while the illness is not yet life-threatening.2 One important aspect of a good quality of end of life denoted by patients and their families is to be cared for at home and to die there.3,4 Because identification of patients with limited life expectancies and urgent palliative care needs can be difficult, patients, family, and their health care professionals are often not timely prepared and educated about appropriate management of problems expected in the future given the disease trajectory. Advance care planning about patient’s wishes and goals of care often take place too late. Consequently, many patients with advanced cancer and a limited life expectancy are admitted to an emergency department (ED), leading to hospital admissions and in-hospital deaths.5-8 Commonly reported physical problems in patients with advanced cancer visiting the ED are pain, respiratory distress, gastrointestinal problems, fatigue, disease progression, delirium and loss of consciousness.5,8-11 One study found that the most common reason for ED visits in the last 2 weeks of life was not being able to cope with the situation at home.5 Other reasons for patients and families to go to the ED are anxiety related to the disease; being defaulted to previously used health care services; feeling safe in and familiar with the hospital setting; and difficulties accessing community health care services, especially when the complaints were urgent or occurred during out-of-office hours.12,13 It is plausible that although patients consider ED visits as unwanted and as a ‘last-resort’ solution for relieve of their problems, their distress caused by their disease and care burden leads to these ED visits.13 ED physicians perceive several barriers to provide appropriate palliative care: the ED is an uncomfortable setting for dying patients,14 physicians work under time pressure which makes palliative patients a low priority,15 they lack confidence in their own palliative care skills,16 do not build a long-lasting relationship with palliative patients and are consequently not comfortable with discussing limitations on medical treatments.15,17 Identification of advanced cancer patients with palliative care needs and a short life expectancy at the ED can help to improve the quality of the end of life by arranging appropriate care. Prediction scores for short-term death in advanced oncology patients are present, but they are not validated for the ED and are mostly extensive assessment tools requiring patient information that is not always accessible in an emergency-setting.18 3
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