Characteristics of patients enrolled in hospice presenting to the emergency department

Objectives: Emergency Departments (EDs) frequently care for patients with life-limiting illnesses, with nearly 1 in 5 patients enrolled in hospice presenting to an ED during their hospice enrollment. This study investigates the reasons patients enrolled in hospice seek care in the ED, the interventions they receive, and their outcomes.

Methods: Multicenter, retrospective cohort study of patients enrolled in hospice who presented to an ED within a health system between 2018 and 2023. Descriptive analysis included patient characteristics, chief complaint, interventions, disposition, ED return visits and mortality. Comparisons were made via logistic regression between patients with a hospice enrollment diagnosis of cancer vs non-cancer diagnosis, patients enrolled in hospice for <30 days vs those enrolled for ≥30 days, and patients admitted to the hospital compared with patients not admitted.

Results: A total of 119 ED visits by patients enrolled in hospice were identified. Patient median age was 85 (IQR: 68-92) years, 38 % were female, and 86 % were White. Hospice diagnoses included cancer (31 %), heart disease (21 %), lung disease (13 %), and dementia (13 %). At the time of ED visit, patients were enrolled in hospice for a median of 71 (IQR: 17-162) days. Patients primarily presented via emergency medical services (EMS) (76 %) from a home residence (51 %). The most common reasons for ED visit were trauma (36 %), pain (15 %) and catheter/tube malfunction (12 %). Most patients received laboratory studies (60 %), medications (66 %) and imaging (64 %). A total of 45 % were admitted to the hospital, with 2 % expiring in the ED. Patients admitted to the hospital were more likely to be receiving hospice services at home (66 % vs. 34 %, p = 0.003). Seven-day mortality was 20 % and 30-day mortality was 38 %. Ten percent returned to the ED within 7 days and 17 % within 30 days. Patients enrolled in hospice for ≥30 days were less likely to return (30 % vs. 51 %, OR 0.26, 95 % CI 0.075-0.94) or die (30 % vs 51 %, OR 0.40, 95 % CI 0.19-0.87) within 30 days compared to those enrolled for <30 days. Patients with a hospice diagnosis of cancer were more likely to die within 7 days (32 % vs 15 %, OR 2.78, 95 % CI 1.11-7.04) compared to patients with a non-cancer hospice diagnosis. In addition, those with a cancer hospice diagnosis (62 % vs 27 %, OR 4.48, 95 % CI 1.96-10.22) and those admitted to the hospital (48 % vs 16 %, OR 2.38, 95 % CI 1.11-5.11) were more likely to die at 30 days than those with a non-cancer enrollment diagnosis or those not admitted, respectively.

Conclusion: Patients enrolled in hospice most frequently presented to the ED for trauma. Most received laboratory studies and imaging. Nearly half of patients were admitted to the hospital and short-term mortality was high, particularly for patients enrolled in hospice for <30 days, enrolled with a hospice diagnosis of cancer, or admitted to the hospital. Understanding the care patients enrolled in hospice receive in the ED can help prevent avoidable visits and ensure care aligns with patients' goals.