ED Hospice Referrals Improve Care and Decrease Length of Stay

By Stacey Kusterbeck

Many ED patients who could benefit from hospice care are instead admitted to the hospital. This is largely due to lack of time and resources in EDs to arrange for hospice care. “We know that with patients who would benefit from hospice care, once you put them in the hospital, they often get care they don’t want,” says Kelly Bookman, MD, professor and vice chair of operations at the Department of Emergency Medicine at University of Colorado.

A good example is an end-stage cancer patient who develops a blood infection. Once admitted, the patient is likely to undergo daily blood draws, to be frequently interrupted by nurses taking vital signs, to experience pain due to placement of large intravenous (IV) lines, and to get inadequate pain management. “In this case, it would be better to make a hospice decision and allow the patient to pass with comfort care rather than prolong the dying process by treating the infection,” says Bookman.

Bookman and colleagues at University of Colorado Hospital wanted to facilitate hospice referrals in the ED. The group developed a clinical pathway for emergency physicians (EPs) and advanced practice providers to identify ED patients who might benefit from hospice care. The pathway uses validated criteria, including the question: Would you be surprised if this patient lived longer than weeks or months? If the patient meets the criteria, the patient is potentially hospice-eligible. “First and foremost, we always look at: What’s the right thing to do for our patients? We are doing the right thing by keeping a patient who doesn’t need to be in the hospital, out of the hospital,” says Bookman.

Once a patient is identified as hospice-eligible, a palliative care social worker gets involved. The social worker talks with the patient and family, handles all of the paperwork, and works with hospice care providers to arrange placement.

“Hospice care allows patients to spend whatever time they have left comfortable and surrounded by their families. Many die at home according to their wishes instead of in-hospital,” says Bookman. The new process has allowed many more patients to be evaluated for hospice while in the ED. For patients who were still admitted to the hospital, admission length of stay decreased by a median of 18.3 hours.¹

The pathway also has benefited ED clinicians, who already knew hospice was clearly the best option for some patients. However, it was just not feasible to have lengthy discussions and keep the patient in the ED for six to eight hours to arrange for hospice care. “Instead, staff clicked on the ‘easy button’ to admit the patient,” says Bookman. Getting a patient admitted was simple and fast, but clinicians felt that it was not the right thing to do for hospice-eligible patients. Now, all that is required for a hospice referral is for ED providers to click on the pathway. “So, there is still an ‘easy button.’ It just gives you a better outcome,” says Bookman.

To prevent hospice-eligible patients from getting admitted, “lots of things have to happen,” says Bookman. EDs need someone in the department to handle the logistics. Hospice providers in the community must agree to accept ED patients. At the University of Colorado’s ED, both of these problems were solved by adding two full-time palliative care social workers. “Most EDs don’t have the luxury of having that kind of resource,” Bookman acknowledges. The team obtained buy-in from hospital administrators with data showing the return on investment of preventing unnecessary admissions. If ED clinicians can prevent 10 unnecessary admissions a month, for example, which can be backfilled with necessary admissions, this gets people’s attention. “When you are talking to a CFO, you can’t just say, ‘You need to pay for a social worker because it’s the right thing to do.’ In reality, the hospital can’t just fund everything because it’s the right thing to do,” explains Bookman.

“It takes a lot of work upfront to get something like this in place,” acknowledges Bookman. “But it benefits everybody — the hospital, the clinicians, and most importantly, patients are actually getting what they need.”

Miscommunication between family members and patients’ providers can hinder hospice referrals. There may be disagreements between family members, making it unclear who has power of attorney or legal decision-making authority for the patient. “There is typically a lot of back-and-forth before the final decision is made to initiate hospice,” says Caitlin Lentz, JD, a health law attorney at Hamil Little. Patients and their families can be harmed by not receiving hospice care when they are eligible and they request it, emphasizes Lentz. “A physician once told me that a main reason patients and their families sue providers is when the patient suffers,” notes Lentz. If a patient is suffering from a terminal illness with only months to live and is focused on comfort, it can be harmful for that patient to undergo treatments and procedures that may cause pain or discomfort. It also causes trauma to the patient’s family. “Caring for a patient can look vastly different from patient to patient,” says Lentz. “It can be saving a life, prolonging a life, or simply making the end of a life more comfortable.”

REFERENCE

1. 1.Wendel SK, Whitcomb M, Solomon A, et al. Emergency department hospice care pathway associated with decreased ED and hospital length of stay. Am J Emerg Med 2024;76:99-104.