JOURNAL OF PALLIATIVE MEDICINE

Volume 19, Number 6, 2016

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2015.0369

Effectiveness of Emergency Department Based

Palliative Care for Adults with Advanced Disease:
A Systematic Review

Duarte da Silva Soares, MSc,1 Cristina Moura Nunes, MD,1 and Barbara Gomes, PhD2

Abstract
Background: Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evi-
dence on best practice is scarce.
Objectives: To examine the effectiveness of ED-based PC interventions on hospital admissions (primary out-
come), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults
with advanced disease.
Methods: We searched five databases until August 2014, checked reference lists/conference abstracts, and
contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting
outcomes of ED-based PC.
Results: Five studies with 4374 participants were included: three case series and two cohort studies. Inter-
ventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital
admissions: in one study there was no statistically significant difference in 90-day readmission rates between
patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after
hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following
ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC
group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other out-
comes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience
an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21–3.41); another study showed
increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate
when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value).
Conclusions: There is yet no evidence that ED-based PC affects patient outcomes except for indication from
one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is
introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these
findings alongside other potential benefits and survival effects.

Introduction consequences,1 which include changes in the use of health

care services and costs,2 such as an exponential increase of
health resources utilization towards the end of life (EOL).3
S ince the mid-twentieth century the world popula-
tion has been rapidly aging, potentiated by decreasing
birth cohorts and increases in life expectancy.1 This phe-
As the number of deaths is predicted to continue to rise in the
future, high numbers of hospital deaths become difficult to
nomenon has particular impact in the older population (aged sustain and an ‘‘expansion of palliative care (PC) provision
60 years or over). People who survive to age 60 can expect to will need to happen in all settings.’’4
live 20 additional years, and the global share of older people Emergency departments (EDs) are highly vulnerable to this
is predicted to continue to grow, reaching 21.1% by 2050.1 demographic transition. They are not only seen as an avail-
The aging of populations has major social and economic able option to seek relief from pain and other burdensome

1
Department of Palliative Care, Unidade Local de Saúde do Nordeste, Bragança, Portugal.
2
Department of Palliative Care, Policy, and Rehabilitation, Cicely Saunders Institute, King’s College, London, United Kingdom.
Accepted January 5, 2016.

1
2 DA SILVA SOARES ET AL.

symptoms,5 but as an accessible entry point to a high- intervention that was described as such by the authors and
technology health care system.2 While not originally con- that was provided at the ED, with the requirement of being
sidered an ideal environment to deliver PC, EDs face the provided by at least one member of a PC team (e.g., social
challenge of receiving growing numbers of patients at the worker, nurse, or physician). Studies not written in English,
EOL.2 Many patients with serious and life-threatening illness Spanish, Portuguese, French, or Italian were excluded due to
present to EDs, because symptoms cannot be controlled in the translation limits. Studies were also excluded if full publi-
community setting.2,5,6 Emergency medicine (EM) providers cations were not available.
may have limited training and resources to manage and re-
spond well to patients in the ED who have PC needs, nor to Data extraction
fully respect these patients’ preferences and expectations.7–10
There is scarce evidence about how ED services can best A data extraction form was developed specifically for the
manage patients that are both clinically and socially complex, review. This included items recording study identification,
promoting continuity of care and preventing unnecessary methods, participants, intervention, outcome measurement,
admissions.2 and results.
Interest in the interface between EM and PC is recent but
has been growing—supported by preliminary data11 that Quality assessment
suggest these interventions might help to identify PC needs Studies were independently assessed for methodological
and reduce acute hospital admissions by promoting admis- quality by two reviewers (DS and CN), using tools according
sion to a PC unit instead, reduce length of stay (LOS), and to the study design. Three of the included studies were case
reduce costs.5 Reducing hospital admissions is key to ensure series, for which we used the National Institute for Health and
that patients stay for as long as possible at home in their last Care Excellence (NICE) quality assessment tool for case
months of life. There is extensive evidence showing that this series.15 Two studies were cohort studies; for these, we used
preference is shared by the majority of patients with ad- the Scottish Intercollegiate Guidelines Network (SIGN)
vanced illness.12 Therefore, in this systematic review we aim checklist for cohort studies.16
to examine and compare the effectiveness of ED-based PC
interventions on hospital admissions (primary outcome), Analysis
LOS, symptoms, quality of life (QoL), use of other health
care services, and PC referrals for adults with advanced The characteristics and results of the studies were narra-
disease. tively reported in synthesis tables. For the primary outcome
(hospital admissions), we have reported quantitative data
Methods when available from the papers or through the authors. For
secondary outcomes (LOS, symptoms, QoL, use of other
The review was performed according to the Preferred health care services, PC referrals), we reported the results
Reporting Items for Systematic Reviews and Meta-Analysis according to the measure used. A meta-analysis was not
(PRISMA) statement13 and followed a predesigned protocol. performed due to limited results.

Identification of studies Results

Search strategy. We searched five databases (MED- Search results
LINE, EMBASE, CENTRAL, PsycINFO, and NHSEED) up
to August 2014 using search terms ‘‘Palliative’’ and ‘‘Emer- Electronic searches identified 5301 hits, resulting in 4015
gency’’ or their equivalents combined with the operator AND. references after duplicate removal. Through screening of title
In addition, we hand searched recent issues of relevant journals and abstract, 3986 references were excluded. We then ex-
that were not fully indexed in databases, screened the refer- amined the full text of the 29 remaining references. Five
ences of relevant reviews and all included studies, screened studies were included. Reasons for exclusion are presented in
proceedings of conferences in the field, and contacted 29 ex- Figure 1.
perts to identify further eligible studies.
Design and setting
Study selection. Studies were first screened by one re- Three studies are case series and two are cohort studies
viewer (DS) who read titles and abstracts and then by two with intervention and control groups (see Table 1). Four
reviewers (DS and CN) who independently read the full text. studies originated from the United States (conducted between
Studies were included if they provided original data evalu- 2005 and 2010), all from major academic inner city tertiary
ating any type of PC intervention or service at the ED for medical centers. One study was European, including 174 EDs
adult patients (18 years or older) with advanced disease. This across France and Belgium, conducted in 2004 and 2005.17
was aligned with Beynon et al.’s broad criteria for PC needs
in an ED setting:14 diagnosis of cancer, or chronic obstructive
Participants
pulmonary disease (COPD), or heart failure (HF), or renal
failure, or liver failure, or neurological disease (multiple In total, 4374 participants were included, with a mean of 875
sclerosis, Parkinson’s, dementia, or motor neuron disease), or participants per study (ranging from 89 to 2420 participants).
>2 comorbidities on the Charlson Index. Four studies included patients with cancer—16.5%17 to
We included interventional controlled studies (experi- 51%18—and noncancer conditions—44.6%19 to 83.5%.17 The
mental and quasi-experimental studies), pre-post studies, latter predominantly included advanced dementia, HF,
cohort studies, and case series. We considered any type of PC COPD,18 renal and liver diseases.19–21 Median/mean age ranged
EMERGENCY DEPARTMENT PALLIATIVE CARE 3

from 66 to 90 years. Gender distribution ranged from 36%21 to Case series

58%22 for males and 42%22 to 64%21 for females. Using the NICE quality assessment tool for case series,13
the quality of the three case series was considered moderate
Types of interventions (see Fig. 2). All case series were single-center and the data
We found three main types of ED-based PC interventions, were collected retrospectively. Other methodological weak-
described according to the level of cooperation between ED nesses were related to lack of clarity of the hypothesis, aim,
and PC services: and objectives,17,18 inclusion/exclusion criteria,19 data col-
lection,18 and outcomes measured.17–19
 ED screening tool used by PC members: Glajchen
et al.;19 this is a rapid two-stage screening protocol Cohort studies
(BriefPal) that was developed to improve referral of
frail older people in ED to PC or hospice care Using the SIGN methodology checklist for cohort stud-
 Traditional PC consultations in the ED: Van Tricht ies,14 the quality of the study by Van Tricht et al.20 was con-
et al.,20 Mahony et al.,21 and Lamba et al.22 In these sidered low (0) while the quality of the study by Wu et al.21
interventions, there is typically no specific collabora- was considered acceptable (+). The two studies reported clear
tive relationship to help integrate PC principles into the aims, and the intervention and control groups were selected
fabric of ED care23 from similar and comparable source populations. However,
 Integrated ED PC services: Wu et al.;18 these programs Van Tricht et al.20 do not clearly state their hypothesis, there is
are characterized by a more formal working relation- a lack of information on missing data, and the outcomes are
ship between the ED and PC program to define part- not clearly stated. Methodological strengths of the study by
nership goals and objectives23 Wu et al.21 include having a clear aim and hypothesis; and
information on missing data, outcomes, limitations, and re-
Results from quality assessment are discussed below and sults. However, since both studies are retrospective cohort
are shown in Figure 2 with dots to aid interpretation. studies and the outcome assessment was not blinded to the
exposure status (ED-based PC consultation or standard care),
according to SIGN the rating of these two studies cannot be
rated higher than ‘‘+’’ (acceptable quality).14 Effects of the
interventions are discussed below and summarized in Table 2.

Hospital admissions
In two studies the authors reported information on hospital
admissions (1726 patients). Wu et al.18 found no statistically
significant differences in 90-day readmission rates. The au-
thors stated that 11/50 patients (22.0%) that initiated PC at
the ED (integrated ED PC) were readmitted, compared to
179/1385 (12.9%) of those that initiated PC after hospital
admission. Mahony et al.21 reported on hospital admissions
but without comparison with a control group: 90% of the 291
patients that were seen by the ED-based PC team (traditional
PC consultations) were admitted to the medical center during
the 14-month timeframe of the study.

Length of stay
In two studies the authors reported information on LOS
(1524 patients). Wu et al.18 reported the mean LOS for the
intervention group (patients who received ED-based PC;
n = 50) was 4.32 days (SE 0.68) compared to 8.29 days (SE
0.36) in the control group (without ED-based PC; n = 1385).
In multivariate analysis (controlling for covariates and pro-
pensity scores), the initiation of PC at the ED (versus after
hospital admission) was still associated with shorter LOS,
with a mean decrease of 3.63 days ( p < 0.01). Lamba et al.22
described the ‘‘average’’ hospital LOS of patients for whom
an ED-based PC consultation was initiated was two days
(without comparison with a control group).

Symptoms
In one study the authors reported information on symptoms
FIG. 1. Preferred Reporting Items for Systematic Reviews (Glajchen et al.19). Patients in the intervention group (patients
and Meta-Analysis (PRISMA) flowchart. screened by BriefPal) reported symptom reduction in pain,
 Table 1. Characteristics of the Included Studies
Use of other health Referrals to
Study Data Hospital Impact on care palliative care NICE
reference Setting Methodology collection Participants Intervention Outcomes admissions Length of stay symptoms Impact on HQoL services services SIGN

Glajchen Beth Israel Med- Case series; May – n = 139 (51 Two-stage Referrals to Not assessed Not assessed n = 112 (follow-up) Not assessed Not assessed At the peak of NICE 4/8 (+)
2011 ical Center, single center December referred to PC; 88 screening specialist PC; reported implementa-
New York, 2007 not referred); protocol symptoms symptom tion, the
U.S. — large n = 56 male; n = 42 (BriefPal) reduction in BriefPal
academic cancer; mean age and training pain, SOB, project
medical 79.92–80.59 nausea, anxiety accounted for
center with (no comparison) half of all
940 beds and referrals to PC
60,000
annual ED
visits
Lamba New Jersey Case series; March 2008 to n = 89 ED-PC; n = 52 Two advanced NPs Survival, LOS, Not assessed Average hospital Not assessed Not assessed 24% returned to N = 11 (12%) NICE 3/8 (+)
2012 University single center; June 2009 males; subgroup and 2 masters- destination LOS = 2 days ED within 1 discharged to
Hospital, retrospective with mean age at trained postdischarge (0.76 on month and home hospice
U.S. — review of death = 45 years bereavement/ subgroup that 59% within 6
academic, data family support died) months.
urban, level- counselors N = 4 (4%)
1 trauma ED discharged to
(100,000 nursing facility
patient visits/
year)
Mahony Montefiore Case series; April 2005 to n = 291 (847 Two PC NPs work- Hospital admission, 90% of Not assessed Not assessed MVQoL scale N = 131 (45%) n = 83 received NICE 3/8 (+)
2008 Medical single center June 2006 consultations); ing in the ED 11 QoL, destination patients (n = 20); 14 = visited ED in homecare and
Center, females 64%; a.m. – 9 p.m. postdischarge, enrolled were satisfaction the 12 months N = 91 hospice;

4
Bronx, N.Y., mean age 79 – 8.4; Monday through ED use, survival admitted to the with control of postdischarge; correlations
U.S. — N = 61 cancer Friday medical center their physical N = 110 (41.9% between
urban symptoms; from all referral to ED
community 13 = ‘‘loss of admissions) PC and
teaching ability to do discharged to enrollment
hospital, many of the skilled nursing on hospice
80,000 things that I facilities (r = 0.49,
episodes/year like’’ p < 0.001)
Van 174 EDs, both Retrospective November – n = 2420; mean age ED-PC services: Survival, LOS, Not assessed ED-based PC Not assessed Not assessed Not assessed Not assessed SIGN 4/13 (0)
Tricht urban and cohort; December 73 – 15.1; 1196 analgesia, withhold/ associated with
2012 rural (171 in multicenter; 2004 and male; n = 1373 sedation, withdraw life interval between
France and 3 compared April – May received PC hydration, support, time admission and
in Belgium); patients who 2005 (exposed); mouth care, from admission death longer
mainly received ED n = 1047 reposition, to death than 9 hours OR
university PC vs standard standard care emotional (95% CI) 2.75
hospitals; all care (unexposed) support (2.21–3.41)
with PC p < 0.001
mobile units
Wu California Pacific Retrospective January 2006 to n = 1435 (215 Davies ED-based PC service LOS, average time to 90-day Mean LOS Not assessed Not assessed Not assessed Not assessed SIGN 10/13 (++)
2013 Medical cohort with December and 1220 Pacific) consisting of 2 PC consultation readmission; 11/ intervention (downgraded
Center, U.S.; control group; 2010 control; n = 1385; physicians and 50 patients (n = 50) = 4.32 to +; see text)
2 centers multicenter intervention an NP (22%) ED-based days (SE 0.68,
(18,000 and n = 50; mean age PC vs 179/1385 p < 0.01); control
28,000 75.6; N = 768 (13%) that re- (n = 1385) = 8.2-
annual ED female ceived standard 9 days (SE 0.36,
visits) care p < 0.01)

ED, emergency department; HQoL, health quality of life; LOS, length of stay; NICE, National Institute for Health and Care Excellence; MVQoL, Missoula Vitas Quality of Life; NP, nurse practitioner; OR, odds ratio; PC, palliative care; QOL, quality of
life; SE, standard error; SIGN, Scottish Intercollegiate Guidelines Network; SOB, shortness of breath.
EMERGENCY DEPARTMENT PALLIATIVE CARE 5

FIG. 2. Quality assessment of the included studies.

shortness of breath, nausea, and anxiety. These outcomes discharged to skilled nursing facilities, 24.2% to home with
were assessed through follow-up of 112 patients via tele- homecare, and 19.1% were discharged without homecare.
phone contact. However, no information was given about
time points; and no information was given about descriptive Referral to palliative care or hospice care services
or analytic statistics comparing patients who were screened
to those who were not. In two studies the authors examined referrals to other PC or
hospice care services, but neither provided analytical results.
Glajchen et al.19 reported that at the peak of implementation, the
Quality of life
BriefPal screening project accounted for half of all referrals to
In one study the authors reported information on QoL the in-hospital PC service. Lamba et al.22 described that 12% of
(Mahony et al.24). The patient’s QoL was self-reported using the patients who initiated PC at ED were discharged to home hos-
Missoula Vitas Quality of Life Index (MVQoLI; scores range pice (compared to 4% in ICU and 13% in ward-initiated PC).
from -20 to +20; higher scores mean higher QoL). This as- The statistical significance of these differences was not reported.
sessment was done post-ED discharge, although no information
was given on the specific point in time after the discharge. By Survival
then, very few patients completed the MVQoLI (20/291, 6.9%
response rate). The authors reported that of those 20 patients, 14 There were conflicting results on survival. Van Tricht
expressed satisfaction with the control of their physical symp- et al.20 reported that the provision of traditional ED-based PC
toms, and 13 expressed improved ability to communicate with was associated with greater odds of experiencing an interval
people close to them. There was no information on total scores, between ED admission and death longer than nine hours
results comparison pre-post the intervention (consultations by (adjusted OR 2.75, 95% CI 2.21 to 3.41). Wu 201318 reported
two PC nurse practitioners), or with a control group. the risk of mortality for 1435 patients according to the All
Patient Refined Diagnostic Related Group (APRDRG) risk of
mortality (ROM) and severity of illness (SOI).25 The
Use of other health care services
APRDRG is a severity coding methodology that allows as-
Two studies reported information on the use of other health signment of an SOI and ROM score in four categories (minor,
care services. Lamba et al.22 reported subsequent use of ED moderate, major, and extreme risk). This system is used to
by patients who received ED-based PC, but without a com- evaluate resource utilization and predict inpatient mortality.
parison group. Twenty-four percent of patients (21/89) re- The authors reported statistically significant differences be-
turned within one month and 59% (52/89) within six months tween the intervention and control groups ( p < 0.01). In the
of their initial contact with PC nurse practitioners. Four out of latter (standard care; n = 1385), the ROM was 2.3% for minor
the 34 patients that received the ED-based PC and survived risk (32/1385), 22.5% for moderate risk (311/1385), 42.4%
were discharged to skilled nursing facilities. Other destina- for major risk (587/1385), and 32.9% for extreme risk (455/
tions on discharge were home (18/34), home hospice (11/34), 1385). In the intervention group (n = 50), the ROM was 4.0%
and unknown place (1/34). Mahony et al.21 reported that of for minor risk (2/50), 24.0% for moderate risk (12/50), 62.0%
the 291 patients who received the ED-based PC service, 45% for major risk (31/50), and 10.0% for extreme risk (5/50). The
visited the ED in the 12 months subsequent to the index visit direction of these differences suggests higher mortality in the
(compared to 59% in the 12 months before the index visit). Of intervention group. Finally, Lamba et al.22 reported in-
those admitted to acute care (90.0%, n = 262), 41.9% were hospital death rates. In the ED-initiated PC group (n = 89), the
 Table 2. Effects of ED-Based PC Interventions
Outcomes Number of participants (studies) Data Comments
Hospital admissions Two studies, n = 1726: Mahony Mahony 2008: 262 patients (90%) that were attended by No comparison (before and after or
2008, case series, U.S., n = 291; MMC ED-based PC team ended up admitted to the with a control group)
Wu 2013, retrospective cohort medical center during the 14-month time data was
with control group, U.S., n = 1435 collected
Wu 2013: 90-day readmission rates — 11/50 patients No statistically significant
(22%) from intervention group were readmitted versus differences
179/1385 (13%) from control group
LOS Two studies, n = 1524: Lamba 2012, Lamba 2012: ‘‘Average’’ (as stated by the authors) No comparison (before and after or
case series, U.S., n = 89; Wu hospital LOS of patients to whom an ED-based PC with a control group); unclear if
2013, retrospective cohort with consultation was initiated was 2 days ‘‘average’’ represents the mean
control group, U.S., n = 1435 or median, and SD or IQR were
not provided
Wu 2013: Mean LOS for the intervention group (patients
who received ED-based PC consultations; n = 50) was
4.32 days (SE 0.68) compared to 8.29 days (SE 0.36)
in the control group (without ED-based PC
consultations; n = 1385); in multivariate analysis
(controlling for covariates and propensity scores),
the initiation of PC at the ED (vs after)

6
Symptoms One study, Glajchen 2011, case Glajchen 2011: Group referred to BriefPal reported No comparison; follow-up made to
series, U.S., n = 139 ‘‘symptom reduction in pain, shortness of breath, 112 patients via telephone; no
nausea, and anxiety’’ information is given about time
points, percentages, means/
medians, SDs/IQRs, or P values
QoL One study, Mahony 2008, case Mahony 2008: MVQoLI post-ED discharge (20/291 No information was given on the
series, U.S., n = 291 patients, 6.9% response rate): 14 expressed satisfaction exact time point when the tool
with control of their physical symptoms and 13 was administered after discharge;
expressed improved ability to communicate with very low RR
people close to them
Use of other health care Two studies, n = 380: Lamba 2012, Lamba 2012: Subsequent use of ED of patients who No comparison (before and after or
services (includes ED case series, n = 89; Mahony 2008, received ED-based PC: 24% returned within 1 month with a control group)
readmission) case series, n = 291 and 59% within 6 months; 4/34 patients that received
ED-based PC and survived were discharged to skilled
nursing facilities (the remaining 30 had gone home
(18/34) / home hospice (11/34) / unknown place (1/34)
Mahony 2008: ED-based PC services group (n = 291): No comparison (before and after or
45% (n = 131) visited ED in the 12 months subsequent with a control group)
to the index visit; from subgroup admitted (n = 262),
41.9% were subsequently discharged to skilled nursing
facilities, 24.2% to home with homecare, and 19.1%
were discharged without homecare
(continued)
 Table 2. (Continued)
Outcomes Number of participants (studies) Data Comments
Referrals to PC or Three studies, n = 519: Glajchen Glajchen 2011: At the peak of implementation, the No comparison (before and after
hospice care services 2011, case series, n = 139; Lamba BriefPal project accounted for half of all referrals or with a control group); no
2012, case series, n = 89; Mahony to in-hospital PC services information on the usual
2008, case series, n = 291 referral rate
Lamba 2012: 11/89 patients (12%) who received No comparison (before and after
ED-based PC consultations were discharged to or with a control group)
home hospice
Mahony 2008: From n = 550 patients referred by the No comparison (before and after
PC team on discharge (total 894 consultations), 83 or with a control group)
received homecare after discharge and 91 received
hospice services
Survival Three studies, n = 3944: Lamba Lamba 2012: Rates of in-hospital deaths; ED-initiated Significance of differences not
2012, case series, n = 89; Van PC group (n = 89) death rate = 62% (n = 55), compared reported

7
Tricht 2012, retrospective cohort, to 16% ward-initiated PC group (91/583) and 50%
n = 2420; Wu 2013, retrospective ICU-initiated PC group (288/578)
cohort, n = 1435 Van Tricht 2012: ED-based PC associated with an Data adjusted for other variables
interval between ED admission and death longer than not reported
9 hours (adjusted OR 2.75, 95% CI 2.21–3.41,
p < 0.0001)
Wu 2013: APRDRG risk of mortality: Control group All APRDRG ROM and SOI
2.3% for minor risk (32/2385), 22.5% for moderate
risk (311/1385), 50% for major risk (693/1385), 31.8%
for extreme risk (441/1385). Intervention: 4% for
minor risk (2/50), 24% for moderate risk (12/50), 62%
for major risk (31/50), 10% for extreme risk (5/50)
( p < 0.01)
APRDRG, All Patient Refined Diagnostic Related Group; ED, emergency department; IQR, interquartile range; LOS, length of stay; MMC, Montefiore Medical Centre; MVQoLI, Missoula Vitas
Quality of Life Index; OR, odds ratio; PC, palliative care; QoL, quality of life; ROM, risk of mortality; SD, standard deviation; SE, standard error; SOI, severity of illness.
8 DA SILVA SOARES ET AL.

in-hospital death rate was 62% (n = 55), compared to 16% in hand searches. The studies included were all conducted in
the ward-initiated PC group (91/583) and 50% in the ICU- high-income countries. Only one example of ED screening
initiated PC group (288/578). However, the authors did not tools used by PC members31 and only one example of inte-
report the statistical significance of these differences. They grated ED PC services18 were found.
viewed the in-hospital death rate in the ED-initiated PC group Since we conducted the review searches (August 2014), a
as ‘‘very high,’’ justified due to most patients dying early and systematic review of PC screening/referral projects at the ED
at the ED, ‘‘signifying a trend for ED clinicians to request PC was published.32 This did not exclude studies that used non-
consults in those who are imminently dying.’’22 PC personnel to screen patients. From the seven studies
identified, one is relevant to our review but does not change
Discussion our findings. This was a randomized control trial with 134
patients, comparing early ED-based PC referral to usual care
We found no evidence that ED-based PC affects patient
(where PC was provided only if requested by the admitting
outcomes except for indication from one study of no asso-
physician).33 The authors found that early referral increased
ciation with 90-day hospital readmission but a possible re-
the likelihood of receiving a PC consultation, which was low
duction in LOS (by 3.53 days) if integrated PC is introduced
as part of usual care within the ED (18% in the usual care
early at the ED rather than after hospital admission. These
group). Finally, the body of evidence we reviewed has strong
findings must be interpreted with care, as they derive from a
methodological limitations, mainly related to the retrospec-
retrospective cohort study with a small intervention group
tive nature of studies.
(n = 50). However, if confirmed in future studies, this could
suggest that ED-based PC may not avoid hospital read-
Conclusions
mission (possibly inevitable due to the complexity of patients
with PC needs who present at the ED) but may help to plan In this systematic review we found that there is yet in-
and provide a faster discharge. It is important to discuss what sufficient evidence of the effect of ED-based PC interven-
a reduction in hospital LOS means at the EOL. Extensive tions, except for indication from one study of no association
evidence shows that well over 50% of people prefer to be with 90-day hospital readmission but a possible reduction in
cared for and to die at home.12,26 Most patients and caregivers LOS if integrated PC is introduced early at the ED rather than
facing advanced illness also prefer this.12,27,28 Therefore, if after hospital admission. Evidence is very scarce of impact on
the result holds true in future trials, an early initiation of PC at symptom control, QoL, and referrals to specialist PC services
the ED might contribute to decrease trends towards hospi- and use of other health care services. Finally, we found
talized dying, by helping patients who wish to remain at conflicting data on survival that require investigation. There
home spend less time in hospital and go home quicker. is an urgent need for powered and well-conducted random-
Interestingly, we found conflicting findings about the as- ized controlled trials to examine any potential benefits of
sociation of ED-based PC interventions with patient’s sur- these interventions.
vival. Lamba et al. reported different in-hospital death rates,
depending on where PC interventions commenced; and al- Acknowledgments
though the statistical significance of these differences was not
This study would not have been possible without the im-
reported and the ED-PC group was relatively small (n = 89),
portant contribution of the Calouste Gulbenkian Foundation,
the findings indicated there could be more (in-hospital) death
Dr. Jacinta Fernandes and the Unidade Domiciliária de Cui-
in this group (62%) compared to patients who initiated PC at
dados Paliativos—Planalto Mirandês, who generously funded
a ward (16%). The difference is not so large when compared
and supported it. The study was conducted as Duarte Soares’
to patients who initiated PC at the ICU (50%), which suggests
research project for the MSc in Palliative Care at King’s
that the high rates may reflect the acute state of patients at the
College London, integrated in the DINAMO Project, which
ED and ICU, which makes PC interventions more time re-
aims at enhancing advanced training and research to optimize
stricted and closer to death.
home palliative care in Portugal (Principal Investigator –
On the contrary, Wu et al. found a lower proportion of
Barbara Gomes, Scientific Director – Irene J. Higginson, other
people in extreme mortality risk in the group who initiated PC
members – Pedro L. Ferreira, Hélder Aguiar, Ana F. Lacerda,
at the ED (10.0%) compared to those who initiated after
Vera P. Sarmento, Duarte Soares, Rita Canário, Maja de Brito,
admission (32.9%). But the overall direction of differences
Catarina Ribeiro, Diogo M. Branco).
taking into account the other categories (major, moderate,
The authors also wish to thank the library services from
and minor risk) indicates higher mortality risk in the inter-
King’s College London; the authors of the included studies,
vention group—the main difference being in a major risk
who provided the information asked for; colleagues in the
group, which represents 62.0% of all intervention patients
Cicely Saunders Institute and the MSc course, mainly Rita
and 42.4% of controls. Contrarily, Van Tricht et al. reported
Canário, Vera Sarmento, Ana Lacerda, and Bárbara Antunes,
that ED-based PC was associated with two times greater odds
for supporting this project since its inception.
of an interval between ED admission and death longer than
nine hours. The latter results suggest that ED-based PC in-
Author Disclosure Statement
terventions might prolong survival, similar to what has been
found in other recent interventional studies of PC.29,30 No competing financial interests exist.

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