In Thailand, the palliative care system has not been well-established despite an increasing number of patients with incurable illnesses. This study describes the characteristics of palliative patients who visited the ED of the largest tertiary university hospital in Thailand. In the present study, approximately half of palliative patients did not have cancer but had other end-staged diseases, which was discordant with other studies in which most patients included were cancer patients [2, 4,5,6,7, 9,10,11]. Our finding indicates the need to expand the provision of palliative care and the field of palliative research to more extensive and diverse populations.

In many previous studies, dyspnea and pain were among the most common presenting symptoms that brought the patients to the ED [1, 2, 6, 23]. In this study, although we also found dyspnea as the most common chief complaint, pain was only reported in 1.6% of the patients. This discordance might have been because of effective home pain management provided by our healthcare providers and the palliative care team or due to the fact that our ED only provides care for very high-acuity patients triaged as level 1 or 2. While patients presenting with pain are usually triaged to level 3 to 5, and were thus sent to the urgency unit instead, thereby not being included in the present study. Moreover, we found that only a quarter of all patients decided to visit the ED by themselves, corresponding to a previous review stating that palliative patients, most of whom were cancer patients, often did not want to visit the ED [12]. However, in the present study, a significant number of non-cancer patients with neurodegenerative diseases and decreased cognitive ability were also enrolled, thus possibly underestimating the true prevalence of self-decision makers.

Also concordant with many previous studies, the main reason for ED visits in this study was that the patients could not control their symptoms [9, 10]. This could partly reflect the quality of our palliative system of care. In fact, palliative care recognition and utilization were immensely inadequate as only about 20% of the patients, most of whom were those with cancer, had previously visited our palliative clinic. Also, had there been a system of home consultation or home care services, ED visits due to this specific reason could have been reduced. Therefore, improving the quality of the palliative system and promoting its utilization, especially in non-cancer patients, are essential to enhance the well-being of end-of-life patients and reduce ED visits. Nonetheless, the rate of avoidable ED visits in this study was only 1.6% (data not shown), which was significantly lower than in other studies [4, 6, 7, 24], and the discharge rate was only 17.6%, demonstrating the very high-acuity and severity of the patients. Thus, it is questionable if improving the palliative care system will ever reduce ED visits to a large extent. Nevertheless, the lack of a standard system of palliative care might influence the quality of life of palliative patients in general, thus leading to, though unavoidable, unnecessary ED visits. Furthermore, a study by Verhoef MJ, et al. found that patients who had a proactive symptom management plan had lower in-hospital death (29.5%) than those without such plans [2]. Whereas in our study, only a handful of patients had those plans and even a smaller proportion truly understood them, corresponding to such a high rate of in-hospital mortality (48.9%).

The most common ED diagnosis was infection (67.1%), similar to a previous study [2] and concordant with the percentage of antibiotics administration. However, due to the lack of long-term care and hospices, the patients who required intravenous antibiotics had to be admitted. Nonetheless, the proportion of patients admitted to the hospital in this study was not different from other settings with long-term care and hospices implemented [5,6,7]. This paradoxical similarity was most likely because of the limited inpatient beds in our hospital, especially for palliative patients, as most of them had to stay in the ED. This crowding in the ED could also partly explain the high ED mortality rate in the present study [25].

Although approximately 60% of the patients had advance care plan, only 4.9% had a living will. This might have been because of Thai culture and tradition that limit the patients and families, who are the patients’ main caregivers, from discussing about advance care plan despite the patients having chronic diseases or cancer [26]. In fact, most of the main caregivers of the patients in the present study were their children, unlike a study by Lawson BJ, et al., from which the patients’ main caregivers were their spouses [13], who might have been more likely to discuss advanced care planning with the patients and have more influence on the family’s decision based on the Thai culture. Nonetheless, the families and physicians tended to choose the goals of treatment and advance care plan that they see fit and should meet the patients’ expectations [27]. However, our result showed that the patients preferred to die at home while their caregivers preferred otherwise. This finding was similar to a previous study in Thailand, which reported a diverse direction of perceptions between the patients and their caregivers [28]. Consequently, initiating palliative care as early as possible is fundamental to bring the patients and their caregivers together on the same page. The first step usually involves a discussion with all parties involved on the goals of care. Although initiating such an essential step in the ED has shown to provide benefits for the patients and lessen the burden of the health care system by reducing ED visits [1, 29], most emergency physicians were not comfortable doing so primarily because they did not have prior relationships with the patients and their families [2, 12]. Also, they did not consider themselves qualified in terms of knowledge and skills, and some also feared having conflicts with the patients’ families that may result in legal consequences [30]. Furthermore, the quality of this critical step performed in the ED may not be as desirable considering the time constraint in the ED setting.

We also found that having received morphine and a low PPS were associated with both ED and in-hospital death, concordant to a previous study [15]. However, cancer and palliative care team consultation in the ED were only independently associated with higher hospital mortality while failing to show significant associations with ED mortality. This discordance might have been because more patients with cancer were admitted, and very severe patients could have died in the ED before palliative consultation was initiated. In fact, the patients who had palliative care consultation could have been associated with higher in-hospital mortality because their symptoms were so severe, and they were judged to be approaching death, thus triggering the consultation for the purpose of both palliative ward admission and symptoms control. Regardless, these results emphasize the necessity of having a standardized and effective palliative care system aimed at both cancer and non-cancer patients. A specialized palliative care team and palliative care education for healthcare providers in the ED should also be encouraged.

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