The Sooner Patients Receive Palliative Care, the Better the Outcomes
ED consultations help identify patients’ goals
When medical providers address the stress and other suffering patients are experiencing along with their medical needs, patients tend to do much better. That’s where palliative care can be an valuable adjunct to medical treatment. The earlier in the stay there’s a palliative care consultation, the better it is for everyone, says Peter Selwyn, MD, MPH, director of the palliative care program and chair of the Department of Family and Social Medicine at Montefiore Health System in Bronx, NY.
Palliative care is most effective when a consultation occurs shortly after admission or even in the ED, Selwyn says.
“For urgent, unplanned admissions, if we can have a timely consultation and intervention in the emergency department, we can get a sense of the patient’s and family’s goals and wishes so we can have a plan in place from day 1. Palliative care consultations in the emergency department or early in the stay can have a big influence on quality and appropriateness of care, patient and family satisfaction, and the length of stay,” he adds.
Often, survival increases when patients receive palliative care in combination with cancer treatment, says R. Sean Morrison, MD, director of the National Palliative Care Research Center and Professor of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York City.
“We have found that if palliative care gets involved within two days of admission, the savings are greater. And the more seriously ill the patients are, the greater the cost savings,” Morrison says.
A research study at the Icahn School of Medicine determined that palliative care helps reduce utilization among very complex, seriously ill patients with high psychosocial needs. Morrison was the lead author of the study that compared a treatment group of advanced cancer patients with numerous comorbidities from six hospitals who were seen by a palliative care team with a group who received the usual care.
The study found that costs for the group that received palliative care were, on average, 22% lower than those who did not receive a palliative consultation. In addition, the study showed the patients with the highest number of comorbidities had up to a 32% reduction in costs when they received palliative care.
Palliative care improves patients’ quality of life but also provides value to the hospital, Morrison says. Palliative care at Mount Sinai Hospital receives high scores on patient satisfaction surveys, particularly among cancer patients, he says.
At Montefiore Medical Center, palliative care assessments often begin in the ED. The nursing and physician staff as well as the social worker dedicated to the ED have been trained to identify patients who may be eligible for palliative care and to begin the discussion with the patient and their families, Selwyn says.
The palliative care program at Montefiore has a full-time staff who are available to consult with emergency department clinicians as needed. Team members alternate being on call 24 hours a day, seven days a week, and perform about 3,000 palliative care consultations each year.
“We don’t have any strict criteria to identify patients for a consultation, but rely on the impression of the emergency department clinical staff as to patients who could benefit from a palliative care consultation. If the patient or family decide the next step is palliative care or hospice care and consistent with their goals, we may admit the patient directly to the palliative care unit or call in the hospice provider to enroll the patient in hospice care,” Selwyn says.
In some instances, if the emergency department staff determines that patients would not benefit from being in the ICU, they may be diverted to the palliative care unit, depending on the wishes of the family, he says.
Mount Sinai Hospital also takes a proactive approach to identifying patients who qualify for palliative care, Morrison says. In order to facilitate a referral for palliative care as soon as possible, the Mount Sinai palliative care team has educated ED physicians on communication skills that will enable them to talk to patients about a serious illness.
In addition, emergency medicine residents spend time on the palliative care service, and three palliative medicine specialists are embedded in the ED and routinely see people who come in with advanced serious illnesses.
When medical providers address the stress and other suffering patients are experiencing along with their medical needs, patients tend to do much better. That’s where palliative care can be an valuable adjunct to medical treatment.
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