Missed Opportunity to Diagnose Palliative Care Need Among Older Emergency Department Patients in a Middle-Income Country: A Retrospective Study

Figures & data

Figure 1 Enrollment of the subjects.

Table 1 Broad and Narrow Criteria

Broad	Narrow
Cancer	Symptom: pain, breathlessness, nausea, weight loss, confusion, and/or anxiety) and/or complex social needs
Obstructive pulmonary disease
Congestive heart failure
Renal failure
Liver failure
Neurological disease (Parkinson’s disease, multiple sclerosis, dementia, or motor neuron diseases)
Charlson Comorbidity Index > 2

Table 2 Baseline Characteristics

	Group 1, N=30(%)			Group 2, N=131(%)
	Had Palliative Care Plan Before, n=22 (73%)	Missed Opportunity for Palliative Care Plan Before, n=8 (27%)	p -value	Had Palliative Care Plan in the ED. n=79(60.3%)	Missed Opportunity for Palliative care Plan in the ED n=52(39.7%)	p -value
Gender, Female	9(40.9)	4(50.0)	0.698	38(48.1)	28(53.9)	0.520
Age (year), mean (SD)	79.0(9.4)	78.0(9.6)	0.796	80.5(9.0)	82.6(8.1)	0.181
Marital status			0.829			0.465
Married	9 (40.9)	5(62.5)		49(62.0)	30(57.7)
Single	11(50.0)	3(37.5)		17(21.5)	9(17.3)
Widow	2(9.1)	0		13(16.5)	13(25.0)
Number of hospital visits within 6 months (unscheduled)						0.019
1–2 times	8(36.4)	3(37.5)		45(57.0)	42(80.8)
3–4 times	5(22.7)	1(12.5)		25(31.6)	7(13.4)
> 4 times	9(40.9)	4(50.0)		9(11.4)	3(5.8)
Functional status			0.518			0.013
Walk with no help	6(27.3)	3(37.5)		8(10.1)	7(13.5)
Walk with help	5(22.7)	3(37.5)		8(10.1)	15(28.9)
Bed ridden	11(50.0)	2(25.0)		63(79.8)	30(57.7)
Living with relative at home	22(100.0)	8(100.0)		71(89.9)	48(92.3)	0.763
Nursing home				8(10.1)	4(7.7)
Mode of arrival			0.195			0.173
Ambulance	5(22.7)	4(50.0)		32(40.5)	15(28.9)
No ambulance
Underlying diseases
Diabetes mellitus with complications	10(45.5)	5(62.5)	0.682	22(27.9)	22(42.3)	0.086
Stroke	6(7.3)	3(37.5)	0.666	30(38.0)	17(32.7)	0.537
Cancer	7(31.8)	2(25.0)		33(41.8)	8(15.4)	0.001
Hypertension	15(68.2)	8(100.0)	0.143	58(73.4)	47(90.4)	0.017
COPD	1(4.6)	1(12.5)	0.469	12(15.2)	11(21.2)	0.380
IHD	4(18.2)	1(12.5)		15(19.0)	19(36.5)	0.025
CHF	1(4.6)	0		9(11.4)	11(21.2)	0.129
Charlson comorbidity index, mean (SD)	7.6(2.0)	6.8(3.5)	0.806	7.9(2.7)	6.9(2.2)	0.029
ED length of stay, median (IQR)	187(64, 247)	253(186,479)	0.133	240(180,394)	284(204,335)	0.209

Abbreviations: ED, emergency department; SD, Standard Deviation; IQR, Interquartile Range.

Table 3 Chief Complaints and Diagnosis

	Group 1, N=30 (%)			Group 2, N=131(%)
	Had palliative care plan before n=22 (73%)	Missed opportunity for palliative care plan before n=8 (27%)	P-value	Had palliative care plan in the ED.n=79 (60.3%)	Missed opportunity for palliative care plan in the EDn=5 (39.7%)	P-value
Chief complaints
Alteration of consciousness	8(36.4)	3(37.5)	1.000	25(31.7)	16(30.8)	0.916
Dyspnea	6(27.3)	0	0.155	36(45.6)	18(34.6)	0.213
Sudden loss of consciousness	5(22.7)	3(37.5)	0.643	7(8.9)	4(7.7)	1.000
Fever				2(2.5)	2(3.9)	0.649
Diarrhea				1(1.3)	3(5.8)	0.300
Diagnosis
Pneumonia	5(22.7)	0	0.287	26(32.9)	21(40.4)	0.383
Advanced cancer				23(29.1)	4(7.7)	0.004
Acute ischemic heart disease	6(27.3)	3(37.5)	0.589	3(3.8)	6(11.5)	0.154
Sepsis	6(27.3)	2(25.0)	1.000	8(10.1)	1(1.9)	0.086
Urinary tract infection				4(5.1)	5(9.6)	0.482
Stroke				1(1.3)	4(7.7)	0.081

Abbreviation: ED, emergency department.

Table 4 Treatment Received During Hospital Visits

	Group 1, N=30(%)			Group 2, N=131(%)
	Had Palliative Care plan Before, n=22 (73%)	Missed Opportunity for Palliative Care Plan Before, n=8 (27%)	P-value	Had Palliative Care Plan in the ED, n=79 (60.3%)	Missed Opportunity for Palliative Care Plan in the ED n=52 (39.7%)	P-value
ET tube intubation	18(81.8)	7(87.5)	1	34(43.0)	37(71.2)	0.002
Foley catheter insertion	10(45.4)	3(37.5)	1	71(89.9)	49(94.2)	0.525
Intravenous catheter insertion (peripheral)	22(100)	8(100)		79(100)	52(100)
Central venous catheter insertion				1(1.3)	5(9.6)	0.036
Cardiopulmonary resuscitation (CPR)	14(63.6)	8(100)	0.071	14(17.7)	20(38.5)	0.008
Total CPR time (minutes), median (IQR)	45(32, 55)	45(32,60.5)	0.812	27(17,40)	30(21,40)	0.766
Morphine or fentanyl
Intravenous	4(18.2)	0	0.55	66(83.5)	47(90.4)	0.266

Abbreviations: ED, emergency department; ET, endotracheal CPR, cardiopulmonary resuscitation; IQR, Interquartile range.