Palliative care needs of advanced cancer patients in the emergency department at the end of life 63 current study associated with approaching death, suggesting urgent palliative care needs, are depicted: primary lung tumour, dyspnoea, neurologic deterioration, jaundice, and hypercalcemia. Other known triggers for palliative care needs that are easily assessable at the ED were added to the flowchart. In other studies in advanced cancer patients, dyspnoea and respiratory distress are reported as risk factors for approaching death, as are neurological deterioration and gastro-intestinal problems.9,44,45 Hypercalcemia is probably predictive of death because it can be a marker for progressive disease in patients with bone metastases or paraneoplastic syndromes.46 Cachexia was associated with approaching death in our univariable model, and delirium was included in the group with neurological deterioration. Although a decline in performance status is a strong predictor for death,47,48 we could not find an association with death, probably because values were missing for many patients. If advanced cancer patients with urgent palliative care needs are identified at the ED, ED staff may choose to consult the hospital palliative care consultation team. Also, tools for unmet palliative needs screening are available, such as the ‘Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED)’ tool49 or the shorter 5-SPEED tool50. The SPEED is the only palliative care needs assessment tool that is validated for use at the ED; however, it is not yet validated in patients with advanced cancer. Risk assessment at the ED for palliative care needs in patients with cancer Yes (Expected) complex (multiple) problems • Comorbidity • Symptoms • Coping • Existential or spiritual • Distress of the informal caregiver Yes Shift goals of care Curative Palliative OR Disease modifying ↓ Symptom control ↓ Dying Factors associated with early death • Primary lung tumor • Neurologic deterioration or delirium • Dyspnea • Hypercalcemia • Jaundice Yes Any hospitalization within previous 4 weeks for symptom management ED-visit previous 6 months Yes Situation in which complex decisions about treatment or end of life care are to be made Patient whishes palliative care Yes Actions: Is any of the following situations applicable? Goals of care discussion with patient and family Assessment of palliative care needs Quick referral to preferred place with appropriate care Consider palliative care consultation for complex problems Yes No Ask yourself the following questions OR Does this patient have advanced cancer? Would I be surprised if this patient died within the next year? Downar 2017: The “surprise question” for predicting death in seriously ill patients jljkl Fig. 1. Risk assessment at the emergency department for palliative care needs in patients with cancer 3
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