Outcomes of Specialist Palliative Care Consultation for Patients with Advanced Cancer in an Oncological Emergency Department: A Retrospective Analysis

INTRODUCTION

Globally, there were 20 million new cancer cases in 2022, predicted to increase by 77% to 35 million by 2050.^[1] In India, over 1.4 million people are diagnosed with cancer annually, expected to rise by 57.5% by 2040.^[2] Advances in cancer treatment have extended the lives of those with advanced cancer, who often present to the emergency department (ED) due to multiple complex symptoms, inadequate symptom control, poor psychosocial support, or sudden health deterioration.^[3]

Patients frequently exhibit uncontrolled symptoms,^[4] psychological distress from fear and uncertainty about their disease,^[5] and face challenges in accessing community healthcare, particularly during acute symptom exacerbations outside regular hours.^[6,7] Disease progression in end-of-life patients aggravates symptoms and urgent, life-threatening situations, prompting ED visits.^[8] Previous studies report that 30–60% of cancer patients visit the ED in their last month of life^[9-12] and 75% visit the ED in the last 6 months of life.^[9]

Chor et al. demonstrated that introducing palliative care (PC) in the ED is feasible and reduces symptom burden at the end of life.^[13] Most patients preferred to die at home with good symptom control, and distressing symptoms could be managed in the ED, allowing patients to return home.^[14,15] This also reduced the length of hospital stays post-ED admission.^[16,17] Despite the proven benefits of PC in improving patient and caregiver outcomes, literature on its application in the ED, particularly in the context of urban tertiary cancer care hospitals in India and low-and middle-income countries (LMIC), is limited. Understanding the outcomes of PC consultations in the ED and the symptom burden of these patients is crucial for optimising care delivery, improving policies and guidelines, and optimising resource allocation, especially in resource-limited settings.

This study aimed to evaluate the outcomes of patients presenting to the ED for Specialist PC (SPC) consultation. In addition, we analysed the symptom profile and reason for visits to the ED to understand the interventions provided and factors associated with SPC consultation outcomes.

MATERIALS AND METHODS

RESULTS

A total of 31,022 consultations for SPC services were recorded in palliative medicine outpatient clinics, inpatient facilities, and ED settings during the study period. Seven-hundred and twelve (2.29%) consultations were performed in the ED, of which 644 (2.07%) consultations referred for SPC fulfilled the eligibility criteria. 350 (54.3%) consultations in the ED comprised of those in the age group 41–60 years, and 332 (51.6%) were females. The most frequent diagnoses of patients referred for SPC in the ED were lung (n = 106, 16.5%), breast (n = 82, 12.7%), and hematolymphoid (n = 65, 10.1%). For 415 (64.4%) consultations, patients self-presented to the ED, while 159 (24.7%) consultations were for those referred by the primary treating oncology services. In 476 (74%) consultations, patients on presentation were planned for no further disease-directed treatment and best supportive care (BSC) only. A total of 454 (70.5%) consultations occurred on weekdays, and nearly half of them occurred during night hours (n = 321, 49.8%).

The median number of previous outpatient department (OPD) consultations before ED presentation was 1 (IQR = 3). Of the total consultations, 487 (75.6%) were already registered with SPC, while 157 (24.4%) were referred for SPC consultation for the first time in ED. Among these 157 first-time consultations, 89 (56.6%) were female patients. A total of 137 consultations (21.3%) were previously seen by the hospital-based home care team. Two hundred seventy-six consultations (42.9%) had received palliative chemotherapy in the last three months before the ED visit. A total of 355 consultations (55.1%) were already on opioids for pain or dyspnea management. The median oral morphine equivalent (OME) was 30 ± 38.75 mg/day, with doses ranging from 2.75 to 240 mg/day. Forty-nine patients revisited the ED for a total of 69 consults (10.7%), with 37 patients (5.7%) revisiting within 30 days of the 1^st ED consult. Detailed patient characteristics and demographics are presented in Table 1. The median Eastern Cooperative Oncology Group (ECOG) score at presentation was 3 (IQR = 1). The median number of symptoms was 1 (IQR = 1). Dyspnea (n = 237, 39.1%) was the most common presenting complaint for which SPC was sought, followed by gastrointestinal symptoms (n = 150, 24.8%) and pain (n = 149, 24.6%). Forty patients (6.6%) were admitted to the ED for >24 h. Pharmacological treatment was advised during 482 (79.5%) ED consultations. Forty of the 237 consults (16.8%) presenting with dyspnea were prescribed opioids in the ED for breathlessness management. Thirteen (2.1%) consults also received nonpharmacological treatment. Blood investigations, imaging, and procedures were advised in 329 (54.3%), 92 (15.2%), and 151 (24.9%) consultations, respectively. The details of the clinical profiles and medical interventions are summarised in Table 2.

DISCUSSION

Patients with advanced cancer in the ED frequently experience myriad physical, psychological, and spiritual distress, necessitating PC consultations with varied outcomes. Among 644 SPC consultations at a tertiary care cancer centre in India over 22 months, 366 (57%) resulted in discharge, while 166 (26%) led to hospital, hospice, or respite care admissions. Seventy-four patients (11.5%) died. Male patients and those with poor PS were more likely to be admitted than those in the discharge group. Patients with poor PS and cancer progression were more likely to die in the ED. Female patients, those with gastrointestinal symptoms and pain, and those receiving pharmacological treatment had higher discharge rates. The most common presenting symptoms were dyspnoea, gastrointestinal issues, and pain. During our 22-month study period, we recorded 31,022 SPC consultations in palliative medicine at our high-volume urban tertiary cancer centre. Only 2% of 31,022 consults were ED consultations, significantly lower than the 21–29% reported in previous studies.^[14,15] In an earlier study, 47% of PC consultations in the ED resulted in discharge.^[19] In our study, more than half of the patients referred for SPC consults in the ED were discharged home, and more than 90% were discharged within 24 h. Earlier research has also shown that cancer patients visiting the ED required more admissions than noncancer populations.^[20] Our admission rate was less than half that of a retrospective study by Dumnui et al., in which 93(47%) cancer patients visited the ED.^[19] These findings reflect appropriate interventions for patients assessed in both clinic and inpatient settings and timely management of presenting complaints in the ED, indicating appropriate utilisation of resources and effective ED-based PC interventions, respectively. Evidence regarding the mortality rate of advanced cancer patients receiving PC in the ED is conflicting. We found that 11% of patients died after PC consultation in the ED, while Monsomboon et al. reported a 23% mortality rate among advanced cancer patients receiving PC in the ED in Thailand.^[21] Similarly, Workina et al., in their prospective study of 338 cancer patients visiting the ED, reported an 18.9% mortality rate.^[22] In contrast, a population-based Canadian cohort examining ED visits of cancer patients receiving chemotherapy, with only 50% having received PC earlier, reported only 0.3% deaths in the ED.^[23]

We found that different factors affected the outcomes of SPC consultation. Various authors have established that poor PS is an indicator of admission and death in patients presenting to the ED, in both cancer and non-cancer. ^{[19,21,22,24]} We found similar findings regarding PS in our univariate and multivariate analyses.

We found that pain and gastrointestinal symptoms were more predictive of discharge than admission. Notably, while dyspnoea was common in all three consultation outcomes– discharge (16%), admission (20%), and death (18%)–it was not a significant predictive factor for any outcome. Dyspnea, the most prevalent symptom, can be explained by the fact that lung cancer was the most common malignancy in our study population. Moreover, breathlessness in advanced cancer is usually associated with a high oxygen requirement, prompting families to bring the patient to the ED. Addressing reversible causes in the ED can alleviate the symptom burden. Sex was a predictive factor for outcomes following PC consultations in the ED. The number of females was slightly higher than males in our study population (51% vs. 49%), but the outcomes following PC consultations differed considerably between the two groups. Females were more likely to be discharged than admitted, and males were at risk of admission or death. Fifty-seven per cent of the new ED consults were females, which can be attributed to the socio-cultural differences in the Indian subcontinent leading to delayed presentation of female patients to oncology or PC clinics, often leading to the first PC consultation being in the ED. Receipt of pharmacological treatment was predictive of discharge (82.5%). The patients who died received fewer pharmacological treatments (63.5%) than those who were discharged. A possible explanation is that patients who were actively dying were identified, and aggressive interventions were avoided.

Ninety per cent of patients had solid tumours, of which lung cancer was the predominant cancer, consistent with other studies.^[20] Sixty-eight per cent of patients presented with only one symptom. The most common presenting symptoms were dyspnea, pain, gastrointestinal and neurological symptoms, and bleeding. Previous studies have reported similar symptoms in the ED presentations of patients with and without cancer. ^{[20,22,24,25]} Pain, the second most common symptom, was primarily attributed to breakthrough pain from cancer/disease progression, end-of-dose pain, and poor compliance to analgesics. Emphasis on and awareness of BTP medications and their usage may help reduce ED visits. Most patients belonged to the 41–60 years age group, contrasting with other studies reporting a median age above 65 years. ^[19-21,24]

Sixty-five per cent of consultations involved patients either presenting independently or being referred by local physicians to the ED, indicating patient and caregiver awareness of seeking urgent care, even in resource-limited settings. Similar high self-referral rates of 57% and 40% were reported by other authors.^[20,24] Most of the consultations in our study were during weekdays, outside the standard working hours, which is contrary to those reported by many other studies,^[14,21,22] likely due to the easy accessibility and lack of additional financial burden of availing ED services in our setting. Approximately three-quarters of our consultations were for patients only on BSC, likely because of their high symptom burden and poor PS associated with advanced cancers. However, the outcome of consultations was unaffected by the presence or absence of disease-modifying treatments and previous treatment modalities, highlighting a patient-centric approach to symptom relief in our practice. Laboratory investigations were advised for 54% and imaging for 15% of the SPC consults. Various procedures, including thoracic and abdominal paracentesis, oxygen supplementation, and transfusion of blood and blood products, were required in 15% of the patients. These rates contrast with studies with higher utilisation of procedures which can be explained by the regional and temporal differences in patient profiles during which their study was conducted. ^[14,21]

Approximately 55% of SPC consultations were on daily opioids, most often used for pain, followed by dyspnea. This reflects the practice of using opioids early in the course of symptom management, often to provide early relief. The median OME was 30 mg/day (IQR = 38.75). In a study conducted by LeBaron et al., barriers related to prescribing opioids have been extensively discussed in the context of the Indian subcontinent.^[26] Only 10.7% of consults accounted for revisits in the ED during the study period, which is less than the 18.4% in the study by Nordt et al.^[24] This lower rate of ED revisits might be indicative of timely follow-up and the effectiveness of OPD and home-based consultations, thereby reducing the need for ED revisits.

Almost 60% of the patients enrolled in home care were discharged. However, 73.7% of consultations for patients unresponsive on presentation, were those living outside the limits of the city and suburbs, who needed access to hospital-based home care services and limited access to community-based PC clinics or home-care programs. This underscores the necessity for both the availability and training of local physicians in palliative and end-of-life care for advanced cancer patients. Sutradhar et al. also identified similar SPC access limitations, recommending further training for generalist palliative home care nurses.^[27]

Our study had a few limitations. First, this was a retrospective study. We aimed to understand the prevailing standard practice of referrals to SPC in an oncology ED before designing any prospective or intervention study. Second, some variables of interest, such as documentation of the quality of life, comorbidities, discussions regarding advance care planning (ACP), preferred place of care, and death, were not routinely documented, limiting available information. Caregivers and family data were not documented, possibly because of the focus on urgent physical symptoms and management. We also did not document laboratory investigation results or their indications. Further prospective studies exploring these variables in a similar setting will add to the existing knowledge pool. Third, the ED staff did not use any triage tools, and all patients requiring SPC were referred according to standard care protocols. Fourth, this was a single-centre study, and the generalizability of our results to other settings should be explored further. Finally, mortality after ED consultation and survival analysis were not the primary focuses of our study.

CONCLUSION

This is the first large-scale study, encompassing 644 SPC consultations, examining outcomes and factors associated with SPC consultations for advanced cancer patients in an Indian oncological ED of a tertiary care cancer centre, reflecting real-world experiences in a low-resource setting. The most frequent outcome was discharge in 57%, followed by admission (26%). About 11.5% of patients died. PS, symptom type, sex, cancer progression, and pharmacological treatments predicted the outcomes.

Appropriate and timely management of symptoms leads to better patient care outcomes through the integration of palliative medicine in ED. Further research should focus on prospective studies of the use of triage tools, initiating conversations regarding ACP, and survival in the ED setting. The end-of-life care policy pertaining to the ED setting, specifically in a low-resource setting, is the need of the hour to streamline resources for optimising patient outcomes in the ED.