Emergency department physicians are adept at predicting when a patient is likely to die and can facilitate patients’ access to hospice care earlier in the course of their illness, according to recent research published in the Journal of the American Medical Association (JAMA) Network Open. However, improved communication and coordination between emergency department physicians and hospice medical directors may be necessary to ensure these patients receive the care they need.
The physicians participating in the study were asked an interogative known as the “surprise question”: “Would you be surprised if your patient died in the next one month?” For the study, physicians answered this question in regards to 10,737 adults age 65 or older who presented at the emergency department.
The rate of identified patients was 20%; physicians correctly predicted the deaths of two out of every 10 patients. Though this demonstrates low sensitivity, the test has value in identifying eligible hospice patients, according to the study authors.
“Using a surprise question remains an important option for any clinician who is deciding on whether patients should go to hospice or not, and this puts the onus back on clinicians to make that decision,” said Kei Ouchi, M.D., an emergency department physician at Brigham and Women’s Hospital and lead author of the study. “And this works perfectly with hospice referral. What’s happening now is that we don’t catch enough patients who need hospice early enough, and that’s why this surprise question still remains important for finding patients who could benefit from hospice earlier in their disease course.”
Nearly 75% of adults older than 65 who suffer from a life-limiting illness visit the emergency department during the final six months of life, according to the study. Most of these patients have not expressed their goals for care, and between 56% and 99% do not have documentation of their wishes for end of life at the time they come to the emergency department.
Use of the surprise question can prompt conversations about end-of-life care goals. These discussions correlate with lower rates of patients who die in the hospital, lower acuity end-of-life care and increased hospice enrollment, the researchers indicated.
Clinician response is just as important as patient identification, and effective communication between the hospital and a hospice is essential to serving these individuals. However, this type of coordination can be challenging.
“There is communication, but it can be improved. [Emergency physicians] know where to call [the hospice], but sometimes we don’t get the timely responses that we are looking for, Ouchi told Hospice News. “In the emergency department I am seeing as many as six patients at the same time, and if I am placed on hold for an answering service I cannot stay on the line because someone else will probably die before I finish that phone call.”