Chapter 3 60 Factors associated with approaching death Independent risk factors for early death were primary lung tumour (HR 1.69, 95% CI 1.29–2.21, p <0.0001), referral for neurological deterioration (HR 2.01, 95% CI 1.38–2.92, p <0.0001) or dyspnoea (HR 1.57, 95% CI 1.23–2.00) and hypercalcemia (HR 1.92, 95% CI 1.21–3.03, p = 0.005) or jaundice (HR 2.11, 95% CI 1.37–3.26, p = 0.001) (Table 4). Table 4. Risk factors for death after ED-visit Predictors Univariable analysis Multivariable analysis H.R. 95% C.I. P-value H.R. 95% C.I. P-value Primary lung tumour 1.67 1.28-2.18 <0.0001 1.69 1.29-2.21 <0.0001 ED-admission for new and acute problem 0.98 0.79-1.20 0.81 Limitations on LSTs before ED-visit 1.26 1.02-1.54 0.029 NS Main symptom at the ED Neurologic deterioration 1.85 1.29-2.66 0.001 2.01 1.38-2.92 <0.0001 Dyspnoea 1.48 1.17-1.88 0.001 1.57 1.23-2.00 <0.0001 Clinical diagnosis Bleeding 1.37 0.95-1.99 0.096 NS Cachexia 1.43 1.03-1.98 0.034 NS Hypercalcemia 1.80 1.14-2.83 0.011 1.92 1.21-3.03 0.005 Jaundice 2.21 1.44-3.39 <0.0001 2.11 1.37-3.26 0.001 List of abbreviations: H.R. = hazard ratio; C.I. = confidence interval; LSTs = life-sustaining treatments; ED = emergency department DISCUSSION This study provides a detailed description of patients with advanced cancer who visited the emergency department (ED) during the last 3 months of their lives and of the actions undertaken during these ED visits. In most patients, care seemed to focus on disease modification; many patients still received anticancer treatments, and few had proactive symptom management plans in case of progressive symptoms or limitations on lifesustaining treatments documented in their patient records. The ED visit triggered revision of limitations of life-sustaining treatments in the majority of patients. Following their ED visit, 76.0% was hospitalized in poor clinical condition and 29.5% died in the hospital; of those who died within 7 days, 71.2% died in-hospital. Factors associated with approaching death were found to aid identifying those patients with urgent palliative care needs at ED entry, in order to make appropriate decisions concerning their treatment and care trajectories.
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