Palliative care needs of advanced cancer patients in the emergency department at the end of life 61 ED staff, patients and their caregivers consider the ED setting an uncomfortable situation for patients at risk of approaching death.13 Besides the hectic and noisy environment of the ED, there is little space for family members to stay with their sick relatives and to conduct end-of-life discussions. Palliative patients often have a lower priority than patients with acute life-threatening illnesses and therefore spend a lot of time waiting at the ED.15 The overwhelming environment of the ED and uncertainty about the situation increases psychological distress and anxiety in patients and their caregivers.21 For ED physicians, an important reason that makes it difficult to provide optimal care to palliative patients is that they have no long-lasting relationships.13,22 Moreover, they are not trained to provide adequate symptommanagement for and to discuss end-of-life decisions.13,21,22 Notwithstanding, ED physicians are willing to provide palliative care and indicated that in order to enhance a ‘good death’, attention should be directed to the care needs and wishes of patients in the palliative phase visiting the ED.23,24 In our study, patients were exposed to many diagnostic tests (83% underwent blood tests, 63% diagnostic imaging) and stayed at the ED for 3.5 h on average, which was followed by hospitalization in over 75%. Since most patients prefer to spend the end of their life at home, these outcomes are undesirable.3 Few patients in our study had limitations on life-sustaining treatments documented, suggesting that palliative care needs and approaching death had not yet been discussed. Patients and caregivers who are unprepared for or unaware of the problems and symptoms that may occur at the end of life are more likely to visit the ED at the end of life,15,25 especially during out-of-office hours.8,13,26 This is supported by our results: 34% of the patients referred themselves to the ED and 52% of the ED visits occurred out-ofoffice hours. Several studies reported that the majority of the ED visits are undesirable and avoidable, especially those by patients with a very short survival.5,26,27 End-of-life discussions have shown to have the potential to prevent ED visits in the last month of life in patients with ovarian cancer and stage IV lung and colorectal cancer.28,29 Communitybased palliative care effectively reduced the number of ED visits in the last phase of life in advanced cancer patients30 and in the general patient population.31,32 Furthermore, meta-analysis of numerous randomized clinical trials proved that integration of palliative care early in the disease trajectory improves health-related quality of life and symptom intensity in patients with advanced cancer.33 Advance care planning and out-patient symptommanagement may help patients and their caregivers to prepare for the end-oflife trajectory and to avoid unnecessary ED visits by supporting coping with deteriorating health.21,34 Although palliative care is often perceived as end-of-life care, palliative care can be provided concurrently with standard care.35 Hence, timely initiation of palliative care is possible and helps to avoid unnecessary ED visits and can improve quality of life in the end-of-life phase. 3
RkJQdWJsaXNoZXIy MTk4NDMw