Ill, Older Patients Who Rely on Emergency Room Often Live Final Days in Hospital, Study Finds

Half of adults over age 65 made at least one emergency department (ED) visit in the last month of life, in a study led by a physician at the San Francisco VA Medical Center (SFVAMC) and UCSF.

Alexander K. Smith, MD, MS, MPH

Three quarters of ED visits led to hospital admissions, and more than two-thirds of those admitted to the hospital died there.

In contrast, the 10 percent of study subjects who had enrolled in hospice care at least one month before death were much less likely to have made an ED visit or died in the hospital.

“For too many older Americans, the emergency department is a conduit to hospital admission and death in the hospital,” said lead author Alexander K. Smith, MD, MS, MPH, a palliative medicine doctor at SFVAMC and an assistant professor of medicine in the Division of Geriatrics at UCSF.

The study, published in the June issue of Health Affairs, was based on an analysis of health records of 4,518 people age 65 and older who died while enrolled in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement and aging sponsored by the National Institute on Aging.

“Unfortunately, the emergency department is not an ideal setting for patients nearing the end of life,” observed Smith. “Aside from the fact that most patients prefer to die at home, ED visits can be incredibly expensive for patients and families, and contribute significantly to the high costs of care at the end of life.”

In addition, he noted, “the traditional focus of the ED is stabilization and triage, not end-of-life care, while hospice provides care specifically for patients with a prognosis of six months of life or less.”

Smith explained that hospice care, which is free to everyone enrolled in Medicare, is centered on the treatment and relief of symptoms that are common near the end of life, such as pain, nausea, shortness of breath and confusion. “These are quite often the symptoms that lead patients who are not in hospice care to visit the ED,” he said.

The majority of hospice care is provided in the patient’s home.

“The interdisciplinary hospice care team is very skilled at providing relief from other forms of suffering as well, such as spiritual and psychological pain,” said Smith. “They also provide bereavement support for families before and after death.”

To encourage timely enrollment in hospice care, the study authors recommended that governments, health care systems and insurers institute policies that encourage physicians to discuss end-of-life care with patients and their families, including reimbursement for advance care planning.

Smith also noted that even if more patients and families make earlier preparations for end-of-life care, “some patients will still end up in the emergency department near the end of life.” To cope with that eventuality, he said, “we need to encourage policies that will make the ED a place where patients can receive the kind of care they need, such as better care of pain, nausea and other symptoms.” He suggested that a “palliative care pathway” could be created to meet the needs of patients who go to the ED seeking relief from suffering.

Co-authors of the study are Ellen P. McCarthy, PhD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC), Boston, MA; Ellen Weber, MD, of UCSF; Irena Stijacic Cenzer, MA, and W. John Boscardin, PhD, of SFVAMC and UCSF; Jonathan Fisher, MD, MPH, of Harvard Medical School and BIDMC; and Kenneth E. Covinsky, MD, MPH, of SFVAMC and UCSF.

The study was supported by funds from the National Palliative Care Research Center, the National Center for Research Resources UCSF-Clinical and Translational Science Institute (CTSI) and the National Institute on Aging, some of which were administered by the Northern California Institute for Research and Education.

NCIRE — The Veterans Health Research Institute — is the largest research institute associated with a VA medical center. Its mission is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.