In recent years a number of studies1-3 have found that the integration of palliative care into oncology practice results in improved quality of life, better quality of end-of-life care, decreased rates of depression, better illness understanding, and greater patient satisfaction. The highly desirable outcomes of more frequent and earlier access to palliative care are currently not available for most patients with advanced cancer. However, a number of conceptual models for this integration have been developed, including a time-based model, a clinician-based model, a problem-based model, and a system-based model.4 These conceptual models require important clinical sentinel events (eg, hypercalcemia, brain metastases, poor symptom control) as triggers for the palliative care consultation. In the current issue of JAMA Oncology, Grudzen et al5 have demonstrated in an elegant randomized clinical trial that using the emergency department (ED) visit as a sentinel event for a palliative care referral can improve quality of life with no detrimental effects on health services use or survival. The authors5 randomized patients with advanced cancer who visited an ED to a same-day or immediate next-day palliative care team consultation vs usual care. The primary outcome was the change score in the quality of life (measured by the functional assessment of cancer therepy–general [FACT-G]) at 12 weeks, and they observed a robust clinical improvement of approximately 6 points in the intervention group compared with only 1 point in the usual care group. The authors5 did not observe any significant change in important outcomes of health care utilization such as hospice use, hospital days, or intensive care unit (ICU) admission, and they also did not observe any significant change in survival. These findings should not be surprising. Palliative care referrals have been associated with improved quality of end-of-life care, including fewer hospital admissions, fewer hospital deaths, and fewer ICU admissions when those referrals take place in the outpatient setting as compared with the inpatient setting.6 This is likely because outpatient referrals occur earlier in the trajectory of illness, and they allow palliative care teams to interact with patients before some of the catastrophic events that lead to inpatient care. Emergency department referrals provide an inception point that is intermediate between outpatient and inpatient referrals. This later inception point, as compared with outpatient referrals, might explain the limited impact of ED-initiated palliative care on health care utilization. More and better inception points for palliative care are necessary because, in most cases, patients with advanced cancer are referred within 1.5 months of death and after a median of 20 encounters with other medical teams.7 This study has demonstrated that an ED visit by a patient with advanced cancer can provide a unique opportunity for improved access to palliative care and quality of life. Emergency department physicians can become important members of the palliative care team by implementing successful early symptom control measures as well as early referral. The ED might provide earlier access than the inpatient consultation when patients are admitted to the hospital. In addition, patients who are discharged after evaluation at the ED might benefit from immediate referral to outpatient palliative care. Where do we go from here? It is important to define and test criteria for palliative care referral from the ED in daily clinical practice. It is also important to better understand the attitudes and beliefs of both ED physicians and primary oncology teams toward automatic palliative care referrals, as well as the level of adherence to this process when implemented in regular clinical care. It will also be important to understand the attitudes and adherence of patients when referred to outpatient palliative care from the ED. In view of the findings of this study, this research is much needed and justified. Back to top Article Information Corresponding Author: Eduardo Bruera, MD, Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Blvd, Houston, TX 77030 (Ebruera@mdanderson.org). Published Online: January 14, 2016. doi:10.1001/jamaoncol.2015.5321. Conflict of Interest Disclosures: None reported. References 1. Bakitas M, Lyons KD, Hegel MT, et al. The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: baseline findings, methodological challenges, and solutions. Palliat Support Care. 2009;7(1):75-86.PubMedGoogle ScholarCrossref 2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.PubMedGoogle ScholarCrossref 3. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730.http://www.ncbi.nlm.nih.gov/pubmed/24559581.PubMedGoogle ScholarCrossref 4. Hui D, Bruera E. Models of integration of oncology and palliative care. Ann Palliat Med. 2015;4(3):89-98.http://www.amepc.org/apm/issue/view/332.PubMedGoogle Scholar 5. Grudzen CR, Richardson LD, Johnson PN, et al. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial [published online January 14, 2016]. JAMA Oncol. doi:10.1001/jamaoncol.2015.5252.Google Scholar 6. Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-line care in cancer patients. Cancer. 2014;120(11):1743-749.Google ScholarCrossref 7. Hui D, Kim SH, Kwon JH, et al. Access to palliative care among patients treated at a comprehensive cancer center. Oncologist. 2012;17(12):1574-1580.PubMedGoogle ScholarCrossref
JAMA Oncology – American Medical Association
Published: May 1, 2016
Keywords: patient referral,emergency service, hospital,models, organizational,patient care team,point-of-care systems,referral and consultation,palliative care,quality of life,cancer, advanced
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