Emergency department as place of end-of-life care and death in cancer patients

Abstract

Background: Place of death is an important issue in palliative care: many studies showed that patients prefer to die outside of the acute care setting (e.g. at home or in a hospice setting). However, the proportion of deaths in the emergency department (ED) remains high. To better evaluate the characteristics and care of cancer patients using acute care resources at the end of life, we conducted a retrospective analysis of a cohort of patients who died at the ED of IRCCS AOU San Martino - IST in Genoa (Italy) over a one year period. Materials and Methods: This is a population-based descriptive study. All cancer patients who died at the ED of our Institution in 2013 were identified through Hospital Discharge Records. Cases were excluded if the patient died in another department even with a prior admission to the ED. Primary data were collected from patients' hospital charts focusing on reasons for admission and care in the ED. Results: Out of 381 cancer inpatients who died at our Institution in 2013, 254 had prior admission to the ED. Among these patients, 108 (45.4% females and 54.6% males) died at the ED and were included in the present analysis. Median age was 78 years (IQR 69-86). There were 53 patients admitted with red-code, 48 with yellow-code and 7 with green-code. The most common cancer diagnoses were: lung (25.9%), breast (9.3%) and liver (9.3%). Median time in the emergency department was 23.5 hours (IQR 10-58.3). Among patients with available information on the use of chemotherapy or radiotherapy, median time from the last chemotherapy cycle was 41 days (IQR 19-91), and from the last radiotherapy 201 days (IQR 23-312). The main reasons for admission to the ED were: shortness of breath (54.6%), pain (16.7%) and cachexia (14.8%). A total of 135 imaging procedures were performed: the most common were chest X ray (56.3%) and body CT scan (19.3%). The most common treatments administered were: antibiotics (17.6%), pain killers (10.2%) and sedatives (8.3%). A total of 5 patients underwent resuscitation procedures. The awareness regarding the end-of-life stage of the disease in doctors and nurses was not present for 7.4% and 8.3% of patients, respectively. For 18.5% of patients, no meeting with patient's care giver was performed. Conclusions: Cancer patients are heavy users of acute care resources at the end of life. Additional investigations are needed to better assess both the reasons for patients' access to the acute care setting and the appropriate use of resources during this time.