Chapter 3 62 Although early palliative care can avoid part of the ED visits at the end of life, there will still be patients visiting the ED for symptoms that are distressing and unmanageable at home. Additionally, patients may visit the ED when community palliative care services are not available, e.g., outside office hours.15,21 ED visits can be an opportunity to recognize high symptom burden and acute deterioration, which should trigger initiation of appropriate palliative care. This is also known as ED-initiated palliative care.36,37 Grudzen et al. conducted a randomized clinical trial in 2016 on palliative care consultations initiated at the ED in patients with advanced cancer and found that it significantly improved their quality of life.37 Examples of ED-initiated palliative care are, among others, consultations by a specialized in-hospital team, community-based care by a homecare team or hospice team, telephone-based interventions, or admissions to a hospice or a palliative care unit.33 Our finding that physicians documented more limitations on LSTs after the ED visit might indicate that they were well aware of changes in disease trajectories, creating an opportunity for effective ED-initiated palliative care. To facilitate cooperation with palliative care services, both at home and in the hospital, it is recommended to have a checklist with standardized criteria38 for referral with contact details of the palliative care services easily available at the ED. An international consensus panel of 60 experts on palliative cancer care formulated 11 criteria for referral to specialized palliative care: nine needs-based criteria (severe physical symptoms, severe emotional symptoms, request for hastened death, spiritual or existential crisis, need for assistance with decisionmaking or care planning, referral on patient’s request, delirium, brain or leptomeningeal metastases, spinal cord compression or cauda equine) and two time-based criteria (within 3 months of diagnosis of advanced cancer or incurable cancer for patients with a median survival of 1 year of less, diagnosis of advanced cancer with progressive disease despite second-line systemic therapy).39 The severity of symptoms can be measured by using the Edmonton Symptom Assessment Scale (ESAS), a patient-reported outcome measure for symptoms prevalent in the palliative phase which is manageable at the ED.40,41 Although the ESAS is not yet validated in the ED setting, a study by Barbera et al. shows that poor symptom burden scores were associated with higher usage of the ED, suggesting that patients visit the ED particularly with high palliative care needs which should be acted upon as soon as possible.42 To identify patients in whom palliative care should be initiated, survival prediction tools such as the Surprise Question, and prediction scores such as the Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI), Glascow Prognostic Score (GPS) and Prognosis in Palliative Care Study (PiPS) are described.18.43 However, these tools are not validated in patients with advanced cancer visiting the ED. To facilitate appropriate and ED-initiated palliative care, we constructed a flowchart to help ED staff identify advanced cancer patients with urgent palliative care needs (Fig. 1). In this flowchart, factors from the
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