Initiating palliative care consults for advanced dementia patients in the emergency department

Background: Patients with dementia, an underrecognized terminal illness, frequently visit the emergency department (ED). These patients may benefit from ED-initiated palliative care (PC) consultation. Objective: The study's objective was to track the rate of ED-initiated PC consultation for patients with advanced dementia (AD) after an educational intervention, and to categorize decision making for physicians who chose not to initiate consultation. Methods: As part of a quality improvement project at a suburban, tertiary care, university-affiliated medical center, emergency physicians (EPs) were taught to identify AD patients and initiate PC consultation. A convenience sample of patients over age 70 was screened for AD by research staff from July 1, 2012 to August 1, 2012 using the Functional Assessment Staging (FAST) criteria. A questionnaire was then administered to patients' physicians to inquire about barriers to initiating consultation. Questionnaires and medical records of those who met AD criteria were reviewed to examine patient characteristics, disposition information, and consultation initiation barriers. Results: Patients (N=548) over 70 who visited the ED were approached and 304 completed the screening. Fifty-one of the 304 met criteria for AD. Their average age was 86; 33% were male. Eighteen of the 51 (35%) patients received a PC consultation sometime during their ED or hospital stay. Four of the 18 (22%) consultations were ED initiated. In 23 of 51 (45%) unique cases, physicians responded to the questionnaire. The majority felt that a PC consult was not appropriate for patients based on their knowledge, attitudes, or beliefs. Conclusion: Preexisting physician attitudes, knowledge, and beliefs prevent emergency physicians from addressing PC needs for AD patients.