End-of-Life Choice, Palliative Care and Counseling

At the End, a Rush to the E.R.by Jay

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By Paula Span
The New York Times
June 5, 2012

What elderly person wants to spend time in an emergency room? They’re so chaotic and uncomfortable that several hospitals have opened calmer, more specialized emergency units particularly designed for their oldest patients.

But how much more distressing is an E.R. visit for someone who’s within weeks of dying?

Dr. Alexander Smith, a palliative care specialist and researcher at the University of California, San Francisco, can recite a long list of reasons that spending hours in emergency rooms doesn’t make sense for people so close to death. “The emergency department isn’t set up for palliative or end-of-life care,” he told me in an interview. “The attitude of people in emergency medicine is to diagnose and fix, not provide comfort.” They’re trained to act; do-not-resuscitate orders or patients’ distaste for aggressive procedures prevent them from acting.

E.R. staff also are usually meeting their patients for the first time and are unfamiliar with their histories, goals and preferences. Add that frail and frightened patients can wait most of a day to be examined, to undergo tests, to get the results. Also add: “stretchers, cold rooms and a guy in the next bed screaming,” Dr. Smith said.

Sadly, though, in a large national study he undertook with colleagues at U.C.S.F. and at Harvard, more than half the older adults who died had gone to an emergency room during the last month of their lives, and the E.R. visit had led most of them straight to a hospital bed.

The study, published on Tuesday in the journal Health Affairs, shows that more than three-quarters of the patients visiting an emergency room in their final month were admitted to the hospital (where 39 percent spent time in an intensive care unit); 68 percent of those admitted to a hospital died there.

The data, drawn from the Health and Retirement Study, trace the histories of 4,158 people over age 65 who died between 1992 and 2006. They were ailing and disabled: More than two-thirds needed assistance with three or more basic daily activities like bathing, dressing and using the toilet. More than a third were nursing home residents, and more than a third cognitively impaired. Though the survey doesn’t specify precisely what symptoms led them to an E.R., we do know that they suffered primarily from heart failure, pneumonia and stroke.

Not only did 51 percent arrive in their final month, but 75 percent went to an E.R. in their final six months, and more than 40 percent of those went more than once. Their average age at death was 83.

This scenario, in which the E.R. acts as a conveyor belt to hospitalization, runs counter to the death most Americans say they want: at home and at peace. But you can see how it might work that way. “When families arrive at the E.R. toward the end of life, they’re in crisis,” Dr. Smith said. “And decisions are made in that moment that affect the rest of a person’s life.”

Not coincidentally, these panicky visits also result in huge bills. The E.R. itself is an expensive place to treat symptoms. Then the visits may trigger many subsequent hospitalizations and I.C.U. use, which cost even more. Historically, a quarter or more of Medicare expenditures happen in the final six months of life; this pattern may help explain why.

What most troubles Dr. Smith and other palliative care physicians, however, is that this represents a poor way to care for the dying. “We can do better to prepare people,” he said.

With franker and more extensive conversations about end-of-life decisions (never easy) and with better outpatient care, reliance on ill-suited emergency rooms might decline. Some of these health problems can be treated effectively outside of hospitals, studies show, and some need not be treated at all, except to relieve pain and distress.

Which brings us, once again, to the magic word.  Among these sick old people, so close to death, what group only rarely went to emergency rooms? Those who had enrolled in hospice care at least a month before they died. Just 10 percent of them visited an E.R. in their final month, compared with 56 percent of those who weren’t enrolled.

Most hospice patients don’t enroll that far in advance, in part because “many doctors don’t mention the possibility of hospice until people are at death’s door,” Dr. Smith said. Their care at a crucial time might improve, and Medicare costs might shrink, if more doctors did.