Wednesday, June 6, 2012

Emergency Departments as a Place for End-of-Life Transitions


I have always been struck by the question of where individuals would prefer to die. You know, the one where most Americans say they prefer to die at home despite the stark reality that the minority actually end up doing so. It just doesn’t seem like this is really the right question. For me, I don't really care where I die - I'll be dead. What matters is how and where I live for the time that I have left.

This is why I am particularly fascinated by a recent article discussed in the NY Times today and published in Health Affairs by our fellow GeriPal bloggers Alex Smith and Ken Covinsky, as well several other researchers from UCSF and Harvard. The study adds to a growing amount of evidence revealing how and where older American live before death.

There is a lot of interesting findings in this paper that uses data from the Health and Retirement Study, a nationally representative data set, and links it to Medicare claims data. The take home point though is summarized best in the perfectly "Tweetable" title Half Of Older Americans Seen In Emergency Department In Last Month Of Life; Most Admitted To Hospital, And Many Die There.

The rest of the paper is a little longer than a tweet and still very worth reading, but basically back up everything that was written in the title.  Of the 4,158 participants in the study who died:
  • Nearly one out of ten (9%) visited the emergency department on the last day of life
  • Over half (51 %) visited the ED within 30 days before death
  • Three out of every four (75%) had visited within 180 days before death
  • 41% made more than one visit to the ED in the last 6 months of life 
  • Most of those those who visited the emergency department in the last month of life were subsequently hospitalized (77%) and most of those individuals (68%) died in the hospital

The clinical characteristics of these decedents are also particularly striking. These characteristics were based on data from interviews conducted with next of kin after the study participant’s death, and showed:
  • A high burden of chronic conditions - nearly 1 out of 3 had cancer, 1 out of 4 had lung disease, over half had a heart condition, and nearly one out of 3 had a stroke.
  • High levels of functional dependency: 77% were dependent in at least one activity of daily living and 67% were dependent in 3 or more ADLs
  • Cognitive impairment is common affecting more than one out of every three decedents
  • Moderate or severe pain was experienced by nearly half (46%) of the decedents

Not surprisingly the biggest predictor of emergency department utilization was hospice use prior to the last month of life. I was though a little shocked that 10% of this group of early hospice users still used the emergency department in the last month of life, but this is still dramatically less than those who did not get the benefit of early hospice use. 

The high utilization of emergency departments at the end of life reminds me of something that Michael Wolff wrote in a recent New York Magazine cover story: "Dying is a series of stops, of way stations, of signposts. Home. Assisted living. Nursing care. Hospice. You are always moving on."  For me, this reaffirms my belief that the question of where would Americans prefer to die is probably a little to simplistic given that we are dealing with a population of individuals living with multiple serious, chronic illnesses.   

by: Eric Widera (@ewidera)

2 comments:

Sue Wintz said...

Eric – Thanks for this important piece.

As a long-time board certified chaplain currently affiliated with HealthCare Chaplaincy in NYC, and from my experience as a member of the palliative care and ICU teams at major medical centers, two implications jump out to me for our colleagues in palliative care

1. When chaplains have conversations with patients and/or family members before the patient is near end of life, “Their care at a crucial time might improve, and Medicare costs might shrink,” as the NY Times’ Paula Span writes

2. Additionally board certified professional chaplains are an essential resource for any hospital emergency department because their expertise is essential in helping not only patients and families through these scenarios, but supporting and assisting the physicians and staff on the team as well. Emergency rooms should ensure that the organization has chaplains assigned specifically to their teams rather than as 'as-needed-we'll page' status.

joshuy said...

I once asked a patient if he had a preference for where he wanted to die: home, hospital, NH. He looked at me and asked, "How am I supposed to know where I'll be when I die?" I laughed. While we sometimes can influence future things, we don't always control as much as we think we do.