International Journal of

Environmental Research
and Public Health

Article
Admission to the Emergency Department by Patients Being
Followed up for Palliative Care Consultations
Mariana Azevedo Brites 1,2, * , Joana Gonçalves 3 and Francisca Rego 1

1 Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal

2 Family Health Unit Corino de Andrade, Póvoa de Varzim, 4490-602 Póvoa de Varzim, Portugal
3 Póvoa de Varzim—Vila do Conde Hospital Center, 4490-421 Póvoa de Varzim, Portugal
* Correspondence: marianadeazevedobrites@gmail.com

Abstract: Introduction: Palliative care aims to improve the quality of life of patients and families
facing life-threatening diseases. Admissions to the emergency department are considered potentially
avoidable. This study aims to characterize the use of the emergency department by palliative care
patients at a public hospital in Portugal. Methods: This retrospective study included patients who
had their first palliative care appointment during the year 2019; 135 patients were included, with
255 admissions to the emergency department. Descriptive statistical analysis consisted of calculating
the absolute (n) and relative (%) frequencies for categorical variables and medians (Mdn) and
percentiles (P25 and P75) for continuous variables. The multivariable associations were calculated
via logistic models, with the statistical significance set to p < 0.05 and 95% confidence intervals.
Results: Dying in hospital was associated with going to the emergency department. Patients who
died in hospital had more admissions and spent more time there. Conclusion: Emergency department
admissions suggest that there are gaps in the provision of care. It is necessary to anticipate crisis
situations, provide home and telephone appointments, and invest in professionals’ education to
Citation: Brites, M.A.; Gonçalves, J.;
respond to the needs that will grow in the future.
Rego, F. Admission to the Emergency
Department by Patients Being
Keywords: emergency service; hospital; palliative care; health services misuse
Followed up for Palliative Care
Consultations. Int. J. Environ. Res.
Public Health 2022, 19, 15204.
https://doi.org/10.3390/
ijerph192215204
1. Introduction
Cicely Saunder founded the St. Christopher’s Hospice in 1967, laying the foundations
Academic Editor: Paul B.
of the current palliative care movement and the need to implement end-of-life care. The
Tchounwou
initial use of the word “palliative” dates back to 1975 when the first palliative care service
Received: 16 October 2022 at the Royal Victoria Hospital in Montreal was created [1]. The World Health Organization
Accepted: 15 November 2022 has defined palliative care as an approach to improve the quality of life of patients and
Published: 17 November 2022 families who are facing problems associated with life-threatening conditions. Its mission is
Publisher’s Note: MDPI stays neutral to prevent and alleviate suffering through the early identification and treatment of pain
with regard to jurisdictional claims in and other problems, whether physical, psychosocial, or spiritual [2,3].
published maps and institutional affil- More than 56.8 million individuals are estimated to be in need of palliative care
iations. globally, including 31.1 million before and 25.7 million near the end of life. [4]. It was used
in 45.3% of all deaths in 2017 [4]. Oncological disease accounts for about 28% of cases
followed by human immunodeficiency virus (22%), cerebrovascular disease (14%), and
dementia (12%) [4]. Palliative patients from all over the world, aged over 20 years old,
Copyright: © 2022 by the authors. experienced 20 million days of suffering due to poor control of symptoms, namely, fatigue,
Licensee MDPI, Basel, Switzerland. pain, depression, anxiety, dyspnea, confusion, and delirium [3]. These symptoms lead to
This article is an open access article admissions to the emergency department (ED) and hospital admissions, which, along with
distributed under the terms and
hospital death, negatively interfere with quality of life [5].
conditions of the Creative Commons
Studies show that potentially avoidable admissions to the emergency department—defined
Attribution (CC BY) license (https://
as accesses to the emergency department that could have been managed in another type
creativecommons.org/licenses/by/
of health service or even avoided with preventive care—accounted for 19 to 58% of
4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 15204. https://doi.org/10.3390/ijerph192215204 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 15204 2 of 12

episodes [6–9]. These are associated with poor disease management, inadequate availability
of services, and lack of patient literacy for decision-making [10]. Decreased efficiency and
increased healthcare costs are consequences of avoidable emergency department visits [10].
Palliative care is cost effective and simple to apply at home; patients prefer it [11,12].
It is estimated that 400,000 health professionals are involved in the provision of
palliative care, which represents only 0.9% of the total worldwide [13]. The European
Association of Palliative Care recommends two specialized palliative care services per
100,000 inhabitants; i.e., a hospital care team and a home care team [13]. The growing need
for palliative care implies that health systems know the reality, so that they are prepared to
respond to it both in human and organizational terms [13].
This study aimed to characterize the use of the emergency department by patients
followed up in palliative care consultations between time of admission and time of death.
Firstly, we wanted to characterize and identify differences between users and non-users
of the emergency department. Secondly, we intended to characterize patients and the
episodes in the emergency department and identify the factors associated with the use of
the emergency department.

2. Materials and Methods

This retrospective study included patients who had their first consultation in palliative
care at a public hospital in northern Portugal in 2019. We considered an average of 207 per
year and the sample size was calculated taking into account a confidence level of 95%
and a margin error of 5%, with random sampling, and obtained the necessary sample of
135 patients. [14]. The study included deceased adults aged 18 years or more for whom there
was complete information in their clinical files. Patients who were alive at the time of data
collection, in May 2022, were excluded (n = 10). A total of 135 patients were included in the
study and accounted for 65.2% of the total patients admitted for palliative care consultation
in 2019. This led to 255 admissions to the emergency department. The study was authorized
by the Ethics and Data Protection Committee of the Hospital Center. The hospital center
where the study took place has a palliative care team whose mission is to support patients
and families in need of differentiated palliative care. It is a multidisciplinary team that
includes doctors, nurses, a psychologist, and a social worker, working Monday to Friday,
8 a.m. to 5 p.m. Referral to the consultation can be carried out by doctors of any of the
hospital services or by family doctors. The team has a telephone contact, available Monday
to Friday, from 8 a.m. to 5 p.m., for patients and families as well as requests for advice
from other health professionals. It is a consulting team without its own inpatient service
and does not provide home care services. Home palliative care service is not available in
this region.
Data were collected to characterize the patients and their use of health services: gender,
age, marital status, residence (domicile, nursing home, continuing care unit, host family),
time between admission to palliative care consultation and death, number of consultations
between admission to palliative care consultation and death, number of hospitalizations
between admission to palliative care consultation and death, time in the emergency de-
partment, place of death, death in the last admission to the emergency department or
subsequent hospitalization, and hospitalization proposed in palliative care consultation.
It also included data to characterize the episodes of admission to the emergency depart-
ment: main complaint, number of complaints, time of admission, origin, request for the
PC team’s opinion, length, and diagnosis. Statistical analysis was performed using SPSS,
version 26.0. For description of the variables, the absolute (n) and relative (%) frequencies
were used for categorical variables and medians (Mdn) and percentiles (P25 and P75) for
the continuous variables, given their asymmetric distribution. The univariate associations
of the categorical variables were evaluated using the chi-squared test or Fisher’s test in
case the former’s assumptions were not met. Univariate associations of the continuous
variables were evaluated using the Mann–Whitney test or the Kruskal–Wallis test for two
(or more than two) groups. Multivariable associations were evaluated by constructing
Int. J. Environ. Res. Public Health 2022, 19, 15204 3 of 12

logistic models in case the dependent variables are binary. The work used a respective
calculation of the adjusted odds ratio (aOR) and by constructing Poisson models in cases
where the dependent variables are counts with a right-skewed distribution, with calculation
of the adjusted relative risk (aRR). The inclusion of independent variables in these models
was based on the criterion p < 0.10 in univariate analyses, to adjust variables that are more
comprehensive. This, in turn, increases the models’ explanatory power. In multivariable
models, the decision of statistical significance was guided by the criterion p < 0.05, with the
confidence intervals, for this purpose, set at 95%.

3. Results
3.1. Characterization of patients
There were 135 patients. Most were male (n = 75, 55.6%) and married (n = 87, 64.4%).
Oncological disease was the most frequent admission diagnosis to palliative care consul-
tation (n = 87, 64.4%), followed by other causes (cardiovascular and respiratory disease)
(n = 25, 18.5%) and dementia syndrome (n = 23, 10.0%). Most patients lived at home
(n = 117, 86.7%). The most prevalent place of death was the hospital (n = 66.48.9%). The
median age was 82.0 years (P25 = 67.0, P75 = 88.0). The median follow-up time in consulta-
tion was two months (P25 = 1.0, P75 = 5.0). The median number of consultations was five
(P25 = 2.0, P75 = 10.0) (Table 1).
Table 1. Characterization of the patient cohort.

Characterization of the Patient Samples (n = 135) n (%)

Sex
Male 75 (55.6%)
Female 60 (44.4%)
Marital status
Single 25 (18.5%)
Married 87 (64.4%)
Widow 15 (11.1%)
Divorced 8 (5.9%)
Residence
Nursing home 13 (9.6%)
Domicile 117 (86.7%)
Host family 1 (0.7%)
Continuing care unit 4 (3.0%)
Main diagnosis
Other causes 25 (18.5%)
Oncological disease 87 (64.4%)
Dementia syndrome 23 (17.0%)
Admissions
0 61 (45.2%)
1 58 (43.0%)
>1 16 (11.8%)
Place of death
Domicile 39 (28.9%)
Hospital 66 (48.9%)
Nursing Home 9 (6.7%)
Continuing care unit 20 (14.8%)
Host family 1 (0.7%)
Hospitalization proposed in consultation
No 129 (95.6%)
Yes 6 (4.4%)
Age (years) 82.0 (67.0–88.0)
Follow-up time in consultation (months) 2.0 (1.0–5.0)
Number of consultations 5.0 (2.0–10.0)
Results presented in format n (%) for categorical variables and Mdn (P25–P75) for continuous variables. ED,
emergency department.
Int. J. Environ. Res. Public Health 2022, 19, 15204 4 of 12

Most patients (n = 98, 72.6%) went to the Emergency Department. The median length
per episode of the emergency department was five hours (P25 = 3.0, P75 = 9.0). The median
time interval between the last episode in the emergency department and death was five
days (P25 = 1.0, P75 = 15.0). Most deaths occurred during the last visit to the emergency
department (n = 56, 57.1%).

3.2. Differences and Associations Regarding Patients Admitted to the Emergency Department
When including the variables that showed statistically significant differences in a
logistic model, the results suggest that having at least one hospitalization (aOR = 6.65,
95%CI = 1.84, 24.07) and dying in hospital (aOR = 9.20, 95%CI = 2.42, 35.07) are associated
with resorting to the emergency department (Table 2).
Table 2. Associations with admissions to the emergency department.

Univariate Analysis Multivariate Analysis

p-Value aOR (CI 95%)
Did Not Go to the ED Went to the ED
(n = 37) (n = 98)
Sex
Male 21 (56.8%) 54 (55.1%) X2 = 0.03, p = 0.863 (†) -
Female 16 (43.2%) 44 (44.9%) -
Marital status
Married 21 (56.8%) 66 (67.3%) X2 = 1.32, p = 0.252 (†) -
Other 16 (43.2%) 32 (32.7%) -
Residence
Domicile 28 (75.7%) 89 (90.8%) X2 = 5.33, p = 0.043 (‡) 1
Other 9 (24.3%) 9 (9.2%) 0.96 (0.19–4.93)
Main diagnosis
Other causes 4 (10.8%) 21 (21.4%) X2 = 3.23, p = 0.200 (†) -
Oncological disease 24 (64.9%) 63 (64.3%) -
Dementia syndrome 9 (24.3%) 14 (14.3%) -
Hospitalizations
0 30 (81.1%) 31 (31.6%) X2 = 26.62, p < 0.001 (†) 1
1 6 (16.2%) 52 (53.1%)
6.65 (1.84–24.07) (°)
>1 1 (2.7%) 15 (15.3%)
Death during the last
- - - -
visit to the ED
No - - - -
Yes - - - -
Place of death
Domicile 20 (54.1%) 19 (19.4%) X2 = 34.54, p < 0.001 (‡) 1
Hospital 4 (10.8%) 62 (63.3%) 9.20 (2.42–35.07)
Other 13 (35.1%) 17 (17.3%) 0.68 (0.17–2.72)
Age 84.0 (61.0–90.0) 81.0 (68.0–87.0) U = 1601.00, p = 0.295 (§) -
Follow-up time in
1.0 (1.0–3.0) 3.0 (1.0–6.0) U = 1236.50, p = 0.004 (§) 1.14 (0.96–1.36)
consultation
Number of
3.0 (1.0–5.0) 6.0 (2.0–11.0) U = 1307.50, p = 0.012 (§) 1.00 (0.91–1.10)
consultations
(†) Chi-square test; (‡) Fisher test; (§) Mann–Whitney test; aOR, adjusted odds ratios calculated via multiple
logistic models including variables with p-value < 0.10 in the univariate analysis. Results presented in n format (%)
for categorical variables and Mdn (P25–P75) for continuous variables. Bold text indicates statistical significance in
multivariable model guided by the criterion p-value < 0.05 with the confidence intervals set at 95%. ED, emergency
department. (°) one or more hospitalizations included in the analysis.

In the multivariable Poisson model, the variables that showed association in the
univariate analysis were included, even those that showed marginal significance (p < 0.10).
More than one hospitalization (aRR = 2.26, CI95% = 1.52–3.37), death during the last visit
to the emergency department (aRR = 1.48, CI95% = 1.09–2.00) and longer follow-up time
Int. J. Environ. Res. Public Health 2022, 19, 15204 5 of 12

in palliative care consultations (aRR = 1.03, CI95% = 1.01–1.06) were associated with an
increased risk of more episodes in the emergency department (Table 3).
Table 3. Associations with the number of episodes in the emergency department.

Univariate Analysis Multivariate Analysis

Number p-Value aRR (CI 95%)
Sex
Male 2.0 (1.0–4.0) -
U = 986.50, p = 0.130 (§)
Female 1.5 (1.0–3.0) -
Marital status
Married 2.0 (1.0–3.0) -
U = 882.50, p = 0.167 (§)
Other 2.0 (1.0–4.0) -
Residence
Domicile 2.0 (1.0–3.0) -
U = 342.50, p = 0.461 (§)
Other 1.0 (1.0–3.0) -
Main diagnosis
Other causes 3.0 (1.0–4.0) -
Oncological disease 2.0 (1.0–3.0) H = 4.11, p = 0.128 (¶) -
Dementia
1.5 (1.0–2.0) -
syndrome
Hospitalizations
0 1.0 (1.0–2.0) 1
1 2.0 (1.0–3.0) H = 24.52, p < 0.001 (¶) 1.11 (0.77–1.58)
>1 4.0 (3.0–7.0) 2.26 (1.52–3.37)
Death during the last
visit to the ED
No 1.0 (1.0–2.5) 1
U = 860.5, p = 0.043 (§)
Yes 2.0 (1.0–3.0) 1.48 (1.09–2.00)
Place of death
Domicile 1.0 (1.0–1.0) -
Hospital 2.0 (1.0–3.0) H = 2.34, p = 0.625 (¶) -
Other 2.0 (1.0–3.0) -
Age rs = −0.06 p = 0.528 -
Follow-up time in
rs = 0.45 p < 0.001 1.03 (1.01–1.06)
consultation
Number of
rs = 0.37 p < 0.001 1.02 (1.00–1.05)
consultations
(§) Mann–Whitney test; (¶) Kruskal–Wallis test; rs, Spearman’s correlation coefficient; aRR, adjusted relative risks
calculated using multiple Poisson models, including variables with p-value < 0.10 in univariate analysis. Bold text
indicates statistical significance in multivariable model guided by the criterion p-value < 0.05 with the confidence
intervals set at 95%. ED, emergency department.

In the multivariable Poisson model, the variables that showed association in the
univariate analysis were included, even those that showed marginal significance (p < 0.10).
Not having a partner (aRR = 1.56, 95%CI = 1.40–1.73), one hospitalization (aRR = 1.62,
95%CI = 1.39–1.89), more than one hospitalization (aRR = 2.80, 95%CI = 2.37–3.32), death
during the last visit to the emergency department (aRR = 1.78, 95%CI = 1.57–2.01), longer
follow-up time in palliative care consultations (aRR = 1.05, 95%CI = 1.04–1.07), and greater
number of face-to-face or telephone consultations (aRR = 1.02, 95%CI = 1.01–1.03) were
associated with an increased risk of longer total length of episodes in the emergency
department (Table 4).
Table 4. Associations with the total length of episodes in the emergency department.

Univariate Analysis Multivariate Analysis

Length (Hours) p-Value aRR (CI 95%)
Sex -
Male 12.5 (6.0–25.0) -
U = 968.00, p = 0.161 (§)
Female 8.0 (4.0–20.0) -
Int. J. Environ. Res. Public Health 2022, 19, 15204 6 of 12

Table 4. Cont.

Univariate Analysis Multivariate Analysis

Length (Hours) p-Value aRR (CI 95%)
Marital status
Married 9.0 (4.0–20.0) 1
U = 329.50, p = 0.051 (§)
Other 16.5 (5.0–24.0) 1.56 (1.40–1.73)
Residence
Domicile 11.0 (4.0–21.0) -
U = 322.00, p = 0.357 (§)
Other 7.0 (4.0–11.0) -
Main diagnosis
Other causes 19.0 (4.0–37.0) -
Oncological disease 9.0 (5.0–20.0) H = 0.14, p = 0.712 (¶) -
Dementia syndrome 8.5 (4.0–18.0) -
Hospitalizations
0 6.0 (3.0–12.0) 1
1 13.0 (6.0–25.0) H = 13.03, p = 0.001 (¶) 1.62 (1.39–1.89)
>1 21.0 (8.0–49.0) 2.80 (2.37–3.32)
Death during the last
visit to the ED
No 7.5 (3.5–17.5) 1
U = 864.50, p = 0.057 (§)
Yes 13.5 (6.0–24.5) 1.78 (1.57–2.01)
Place of death
Domicile 7.0 (3.0–13.0) -
Hospital 13.5 (6.0–24.0) H = 4.18, p = 0.124 (¶) -
Other 7.0 (4.0–18.0) -
Age rs = 0.17 p = 0.107 -
Follow-up time in
rs = 0.40 p < 0.001 1.05 (1.04–1.07)
consultation
Number of consultations rs = 0.36 p < 0.001 1.02 (1.01–1.03)
(§) Mann–Whitney test; (¶) Kruskal–Wallis test; rs, Spearman’s correlation coefficient; aRR, adjusted relative risks
calculated using multiple Poisson models, including variables with p-value < 0.10 in univariate analysis. Bold text
indicates statistical significance in multivariable model guided by the criterion p-value < 0.05 with the confidence
intervals set at 95%. ED, emergency department.

3.3. Characterization of Admissions to the Emergency Department

There were 251 emergency episodes. More than half (n = 126, 50.2%) were due to
respiratory complaints followed by pain (n = 34, 13.5%), changes in behavior and general
status (n = 34, 13.5%), and gastrointestinal complaints (n = 16; 6.4%). There were more
admissions outside the palliative care team’s working hours (n = 136, 54.2%). The episodes
led to 91 hospitalizations (36.3%). The emergency medical or first aid ambulance was the
most frequent means of admission to the emergency department (n = 165, 65.7%). However,
there were also admissions referred by the palliative care team following consultation
(n = 5, 2.0%) and by primary health care (n = 5, 2.0%). The request for an opinion from the
palliative care team during an episode in the emergency department occurred in a minority
of cases (n = 39, 15.5%). The median length of stay in the emergency department during
the episode was 5 h (P25 = 3.0, P75 = 10.0 h) (Table 5).
There were eight (3.2%) admissions resulting in death in the emergency department,
and the most frequent diagnosis was chronic obstructive pulmonary disease with un-
specified acute exacerbation (n = 46, 18.3%). In four admissions (1.5%) to the emergency
department, patients at admission were already in cardiorespiratory arrest, and these
admissions were excluded from the analysis.
Table 5. Characterization of the patient sample and episodes in the emergency department.

Characterization of Episodes in the ED (n = 251) n (%)

Main complaint
Pain 34 (13.5%)
Respiratory 126 (50.2%)
Gastrointestinal 16 (6.4%)
Changes in behavior or general condition 34 (13.5%)
Genitourinary 14 (5.6%)
Trauma 10 (4.0%)
Other 17 (6.8%)
Int. J. Environ. Res. Public Health 2022, 19, 15204 7 of 12

Table 5. Cont.

Characterization of Episodes in the ED (n = 251) n (%)

Outside the team’s working hours 136 (54.2%)
Hospitalization
No 160 (63.7%)
Yes 91 (36.3%)
Origin
Own initiative 59 (23.5%)
Ambulance 165 (65.7%)
National telephone contact center 10 (4.0%)
Consultation 5 (2.0%)
Primary health care 5 (2.0%)
Other 7 (2.8%)
Request of team’s opinion
No 212 (84.5%)
Yes 39 (15.5%)
Time in the ED (hours) 5.0 (3.0–10.0)
Results presented in format n (%) for categorical variables and Mdn (P25–P75) for continuous variables. ED,
emergency department.

3.4. Associations with the Admissions to the Emergency Department

We included variables that showed association in the univariate model in a multi-
variable Poisson model as well as in those that showed marginal significance (p < 0.10).
As a result, in comparison with the sign or symptom of pain, changes in behavior and
status were associated with longer length of stay in the emergency department (aRR = 1.26,
95%CI = 1.06–1.50). Gastrointestinal changes (aRR = 0.77, 95%CI = 0.60–0.98), urinary tract
signs or symptoms (aRR = 0.63,95%CI = 0.48–0.83), trauma (aRR = 0.59, 95%CI = 0.43–0.83),
and others (aRR = 0.35, 95%CI = 0.25–0.48) were associated with a shorter length of stay in
the emergency department. In comparison to access to the emergency department on one’s
own initiative, an emergency medical or first aid ambulance was associated with a longer
length of stay in the emergency department (aRR = 1.32, 95%CI = 1.17–1.48) (Table 6).
Patients who were most frequently hospitalized were admitted with respiratory com-
plaints (n = 57, 62.6%). The in-hospital team was not asked for an opinion on palliative
care in most situations—both in hospitalized (n = 73, 80.2%) and not hospitalized (n = 139,
86.9%) patients. Hospitalization during the episode in the emergency department was not
associated with the variables evaluated (Table 7).
There was an association (X2 = 4.6, p = 0.032) and a higher prevalence of requests for
the PC team’s opinion (n = 24, 20.9%) in patients admitted during service hours (Table 8).
Table 6. Associations with length of stay in the emergency department.

Univariate Analysis Multivariate Analysis

Length p-Value aRR (CI 95%)
Main complaint
Pain 5.5 (3.0–9.0) 1
Respiratory 6.0 (3.0–12.0) 1.13 (0.98–1.30)
Gastrointestinal 4.5 (2.0–9.0) 0.77 (0.60–0.98)
Behavior 7.0 (3.0–13.0) H = 25.26, p < 0.001 (¶) 1.26 (1.06–1.50)
Urinary 4.0 (3.0–5.0) 0.63 (0.48–0.83)
Trauma 3.0 (1.0–7.0) 0.59 (0.43–0.83)
Other 3.0 (1.0–3.0) 0.35 (0.25–0.48)
Number of complaints
1 5.0 (3.0–10.0) -
U = 3300.00, p = 0.443 (§)
>1 6.0 (3.0–9.0) -
Origin
Own 5.0 (2.0–8.0) 1
Ambulance 6.0 (3.0–11.0) 1.32 (1.17–1.48)
H = 9.54, p = 0.023 (¶)
Contact center 2.5 (1.0–4.0) 0.79 (0.58–1.08)
Other 5.0 (2.0–9.0) 0.89 (0.71–1.12)
Team’s opinion
No 5.0 (3.0–9.0) -
U = 3606.50, p = 0.204 (§)
Yes 6.0 (3.0–13.0) -
(§) Mann–Whitney test; (¶) Kruskal–Wallis test; aRT, adjusted relative risks calculated via multiple Poisson
models, including variables with p-value < 0.10 in univariate analysis. Bold text indicates statistical signifi-
cance in multivariable model guided by the criterion p-value < 0.05 with the confidence intervals set at 95%.
ED, emergency department.
Int. J. Environ. Res. Public Health 2022, 19, 15204 8 of 12

Table 7. Associations with hospitalization during an episode in the emergency department.

Univariate Analysis Multivariate Analysis

Hospitalization p-Value aOR (CI 95%)
No (n = 160) Yes (n = 91)
Main complaint
Pain 25 (15.6%) 9 (9.9%) X2 = 11.02, p = 0.088 (†) 1
Respiratory 69 (43.1%) 57 (62.6%) 2.21 (0.94–5.16)
Gastrointestinal 11 (6.9%) 5 (5.5%) 1.27 (0.34–4.77)
Behavior 22 (13.8%) 12 (13.2%) 1.49 (0.52–4.29)
Urinary 11 (6.9%) 3 (3.3%) 0.71 (0.16–3.19)
Trauma 8 (5.0%) 2 (2.2%) 0.72 (0.12–4.11)
Other 14 (8.8%) 3 (3.3%) 0.58 (0.13–2.54)
Number of
complaints
1 138 (86.3%) 80 (87.9%) X2 = 0.14, p = 0.708 (†) -
>1 22 (13.8%) 11 (12.1%) -
Origin
Own 42 (26.3%) 17 (18.7%) X2 = 6.50, p = 0.090 (†) 1
Ambulance 97 (60.6%) 68 (74.7%) 1.66 (0.86–3.21)
Contact center 9 (5.6%) 1 (1.1%) 0.27 (0.03–2.35)
Other 12 (7.5%) 5 (5.5%) 1.05 (0.31–3.54)
Team’s opinion
No 139 (86.9%) 73 (80.2%) X2 = 1.96, p = 0.162 (†) -
Yes 21 (13.1%) 18 (19.8%) -
Results are presented in format n (%) for categorical variables and Mdn (P25–P75) for continuous variables;
(†) chi-square test; aOR, adjusted odds ratios calculated via multiple logistic models including variables with
p-value < 0.10 in the univariate analysis.

Table 8. Associations with time of admission to the emergency department, including the palliative
care team’s work schedule.

Univariate Analysis Multivariate Analysis

Time of Admission p-Value aOR (CI 95%)
Team Available (n = 115) Team Unavailable (n = 136)
Main complaint
Pain 13 (11.3%) 21 (15.4%) X2 = 4.43, p = 0.619 (†) -
Respiratory 61 (53.0%) 65 (47.8%) -
Gastrointestinal 8 (7.0%) 8 (5.9%) -
Behavior 18 (15.7%) 16 (11.8%) -
Urinary 5 (4.3%) 9 (6.6%) -
Trauma 5 (4.3%) 5 (3.7%) -
Other 5 (4.3%) 12 (8.8%) -
Number of complaints
1 101 (87.8%) 117 (86.0%) X2 = 0.18, p = 0.675 (†) -
>1 14 (12.2%) 19 (14.0%) -
Origin
Own 27 (23.5%) 32 (23.5%) X2 = 0.49, p = 0.920 (†) -
Ambulance 75 (65.2%) 90 (66.2%) -
Contact center 4 (3.5%) 6 (4.4%) -
Other 9 (7.8%) 8 (5.9%) -
Team’s opinion
No 91 (79.1%) 121 (89.0%) X2 = 4.60, p = 0.032 (†) -
Yes 24 (20.9%) 15 (11.0%) -
Results presented in format n (%) for categorical variables and Mdn (P25–P75) for continuous variables;
(†) chi-square test; aOR, adjusted odds ratios calculated via multiple logistic models including variables with a
p-value < 0.10 in the univariate analysis. Bold text indicates statistical significance in univariate analysis guided
by the criterion p-value < 0.05.

4. Discussion
This study allowed us to investigate the characteristics of patients who attended a
consultation to identify their profile regarding the use of health services as well as to
globally analyze the episodes of admission to the emergency department.
Most patients included in this study were elderly, reflecting the important role of
palliative care in the geriatric population. Worldwide, 40% of palliative care needs to
Int. J. Environ. Res. Public Health 2022, 19, 15204 9 of 12

address patients over 70 years of age [4]. The predictions show that the need for palliative
care will increase by about 183% by 2060 [15].
The follow-up time was short and reflects late referral of patients to palliative care.
Late referral collides with the approach that palliative care should be provided as early
as possible in the course of the disease. Late referral is associated with poor symptomatic
control, increased suffering, failure to discuss advanced care plans, caregiver burnout, and
hospital deaths [16]. Earlier transition to palliative care is associated with better symptoms
control, reduced distress, and more respect for patients’ preferences [17]. Early initiation of
palliative care is also associated with reduced late-life acute hospital use [18].
This study enrolled all patients regardless of pathology, although oncological disease
was the most frequent. Worldwide, oncological disease has the highest representation
in need of intervention by palliative care, but more than 70% of needs concern other
health conditions, including human immunodeficiency virus, cerebrovascular disease, and
dementia. These data show the importance of including these populations in studies [13].
Most patients who use the emergency department lived at home, and most patients
resorted to the emergency department despite follow-up in consultation. A greater number
and time of follow-up in consultation was associated with more episodes and time spent in
the emergency department. However, only a few users were advised by the palliative care
team to use this service. Patients feel safer in the hospital than at home. They resorted to
the emergency department due to difficulties in managing the clinical situation at home
despite having caregivers [12,19]. Patients and families seek the hospital due to anxiety
during episodes of worsening symptoms, lack of prior guidance by health teams, search
for security and familiarity, and difficulty in accessing primary care in situations that they
consider to be urgent, including outside regular office hours [20]. The existence of a home
team or telephone network of health professionals with training in palliative care that is
permanent and available to respond to crisis situations potentially prevents patients from
going to the emergency department [20].
Among the patients who resorted to the emergency department, most died during
the last admission or subsequent hospitalization. There were patients who were admitted
in cardiorespiratory arrest and who died during their stay in the emergency department.
Dying in hospital was associated with going to the emergency department. Patients who
died during the last episode of the emergency department or subsequent hospitalization
spent more time and were admitted more often into the emergency department. Patients
with a higher number of emergency department admissions, hospitalizations, and hospital
deaths possibly had a worse quality of life in the last months of life [21]. Care and death at
home are patients’ preference [5,21]. Home care promotes greater comfort, fewer hospital
infections, and cost savings [22]. Late referral of patients and, consequently, the presence
of more severe diseases, might explain the difficulty in symptoms control, emergency
department use, and hospital deaths [16,17].
Most hospitalizations took place following admission to the emergency department.
This result may reflect the fact that the in-hospital palliative care team does not have its own
inpatient unit, which leads patients and families to resort to the emergency department.
Thus, there is an association between going to the emergency department and having been
hospitalized at least once. Patients who had more than one hospitalization presented a
greater number of admissions and a greater total length of stay in the emergency depart-
ment. Patients hospitalized one or more times are twice as likely to be readmitted to the
emergency department [23].
Regarding the analysis of episodes in the emergency department, the frequency of com-
plaints matches other studies that also found pain (15–46%), respiratory disease (13–26%),
and digestive symptoms (12–26%) as the main admission symptoms [7,9,12]. A wide vari-
ety of final diagnoses was obtained, but it is not statistically feasible to look for associations
with the remaining variables. [7,9,12]. Gastrointestinal and genitourinary complaints were
associated with a shorter length of stay in the emergency department. There was often
a correlation with easily resolved clinical conditions that correspond to likely potentially
Int. J. Environ. Res. Public Health 2022, 19, 15204 10 of 12

avoidable episodes, such as constipation, retention, or urinary tract infection. All health
professionals who have contact with palliative patients should be familiar with the man-
agement of this symptomatology to improve symptom control and them resorting to the
emergency department [7,9,12].
There were more admissions after working hours. The palliative care team is only
available from 8 a.m. to 5 p.m., Monday to Friday. Thus, admissions after working hours
might happen because the emergency department is the only health service available in
this period to respond to existing needs. [7,9]. Emergency medical or first aid ambulance
was the most common means of accessing the emergency department. Health professionals
involved in emergency transport recognize the advantages of death at home, but they have
difficulty in promoting this deferral. The use of this resource is associated with a lack of
alternatives in after-work hours, lack of clinical information about patients, and the health
system’s focus on providing life support care [24].
End-of-life patients should not need to resort to an emergency department and should
remain at home, or, when this is not appropriate, be directly referred to a palliative care
unit. It is thus necessary to invest in training and in the organization of the network of
professionals qualified to act, thereby increasing the period of availability of face-to-face,
telephone, or home service. Consultancy to other professionals is also needed to support
the management of crisis situations [19,25,26]. In 2019, Portugal had a ratio of 0.9 palliative
medicine services per 100,000 inhabitants, which is less than the recommendations [13].
In the geographic area studied here, there is no palliative care team available to provide
care at home. The existence of palliative care teams composed of specialists from different
areas (specialized palliative care doctors, nurses, and family doctors) with permanent
accessibility is associated with a lower frequency of admission to the emergency depart-
ment. Palliative care at home significantly increases patient satisfaction, reduces the use
of medical services—whether visiting the emergency department or being admitted to the
hospital—and lowers end-of-life medical care costs. [27].
This study has some limitations. A retrospective analysis was performed, and hence
the collection of information was dependent on its availability in clinical records. The
sample reflects the reality of one region, and patients that were alive at the time of data
collection were excluded, given the small number of patients. These factors should be
considered for the construction and improvement of future studies on the subject. Nev-
ertheless, this study does address a topic that lacks information both at a national and
international level. The conclusions drawn here will help improve health services.

5. Conclusions
The aim of this study was to describe the use of the emergency department by patients
followed up in palliative care consultations until death. The results show that the responses
of the health system do not suit the needs of patients and families given that the majority
had to resort to the emergency department. Dying in hospital was associated with going to
the emergency department, and patients who died in the hospital had more admissions
and spent more time there.
Among the strategies to improve the provision of care, there is the establishment
and creation of action guidelines for professionals. This can combine palliative medicine
services and primary care so that crisis situations can be better managed in the community.
An automatic consulting system can be created for specialized clinicians based on pre-
defined clinical criteria [19,28–31]. A fragmented health system cannot effectively deal
with the increased demand for care due to aging populations, thus increasing long-term
chronic diseases and multimorbidity. Palliative care must be integrated at all levels of
health systems to ensure smooth transitions and continuity of care [32]. Undergraduate
and postgraduate training in palliative care is essential to create a network of health
professionals that can adequately manage the needs of patients [13]. It is necessary to invest
in patient and caregiver education and establish an early care plan. There must also be
organizational responses; e.g., telephone and digital assistance across more hours, for a
Int. J. Environ. Res. Public Health 2022, 19, 15204 11 of 12

timely response to a crisis situation. There is a need for regular contacts and communication
as well as more home visits.
The use of an emergency department by palliative patients is a sign that there are gaps
to be filled in the provision of care. Therefore, solutions must be implemented to respond
to the growing needs in this area.

Author Contributions: Conceptualization, M.A.B., J.G. and F.R.; Methodology, M.A.B., J.G. and
F.R.; Software, M.A.B. and J.G.; Validation, M.A.B., J.G. and F.R.; Formal Analysis, M.A.B. and J.G.;
Investigation, M.A.B. and J.G.; Resources, M.A.B., J.G. and F.R.; Data Curation, M.A.B. and J.G.;
Writing—Original Draft Preparation, M.A.B.; Writing—Review & Editing, M.A.B., J.G. and F.R.;
Visualization, M.A.B., J.G. and F.R.; Supervision, F.R.; Project Administration, M.A.B.; All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Póvoa de Varzim/Vila do Conde Hospital
Center (approved on 19 October 2021).
Informed Consent Statement: Patient consent was waived due to the retrospective, observational
and non-interventional design of the study.
Data Availability Statement: The data supporting the reported results can be found in the Póvoa de
Varzim/Vila do Conde Hospital Center archive.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Eti, S. Palliative Care: An Evolving Field in Medicine. Prim. Care Clin. Off. Pract. 2011, 38, 159–171. [CrossRef] [PubMed]
2. World Health Organization. National Cancer Control Programmes: Policies and Managerial Guidelines, 2nd ed.; World Health
Organization: Geneva, Switzerland, 2002.
3. World Health Assembly 67. Strengthening of Palliative Care as a Component of Comprehensive Care Throughout the Life Course; World
Health Organization: Geneva, Switzerland, 2014.
4. Connor, S.R. The Global Atlas of Palliative Care at the end of Life: An Advocacy Tool, 2nd ed.; Worldwide Palliative Care Alliance:
London, UK, 2020.
5. Gomes, B.; Higginson, I.J.; Calanzani, N.; Cohen, J.; Deliens, L.; Daveson, B.A.; Bechinger, D.; Bausewein, C.; Ferreira, F.;
Toscani, F.; et al. Preferences for place of death if faced with advanced cancer: A population survey in England, Flanders,
Germany, Italy, The Netherlands, Portugal and Spain. Ann. Oncol. 2012, 23, 2006–2015. [CrossRef] [PubMed]
6. Delgado-Guay, M.O.; Kim, Y.J.; Shin, S.H.; Chisholm, G.; Williams, J.; Allo, J.; Bruera, E. Avoidable and Unavoidable Visits to the
Emergency Department Among Patients With Advanced Cancer Receiving Outpatient Palliative Care. J. Pain Symptom Manag.
2014, 49, 497–504. [CrossRef] [PubMed]
7. Wallace, E.M.; Cooney, M.C.; Walsh, J.; Conroy, M.; Twomey, F. Why do Palliative Care Patients Present to the Emergency
Department? Avoidable or Unavoidable? Am. J. Hosp. Palliat. Med. 2013, 30, 253–256. [CrossRef]
8. Taylor, P.; Stone, T.; Simpson, R.; Kyeremateng, S.; Mason, S. Emergency department presentations in palliative care patients: A
retrospective cohort study. BMJ Support. Palliat. Care 2022, 1–4. [CrossRef]
9. Alsirafy, S.A.; Raheem, A.A.; Al-Zahrani, A.S.; Mohammed, A.A.; Sherisher, M.A.; El-Kashif, A.T.; Ghanem, H.M. Emergency
Department Visits at the End of Life of Patients With Terminal Cancer: Pattern, Causes, and Avoidability. Am. J. Hosp. Palliat.
Med. 2016, 33, 658–662. [CrossRef]
10. Balakrishnan, M.; Herndon, J.; Zhang, J.; Payton, T.; Shuster, J.; Carden, D. The Association of Health Literacy with Preventable
ED Visits: A Cross-Sectional Study. Acad. Emerg. Med. 2017, 24, 1042–1050. [CrossRef]
11. World Health Organization Expert Committee on Cancer Pain Refief and Active Supportive Care; World Health Organization.
Cancer Pain Relief and Palliative Care. In Proceedings of the WHO Expert Committee, Geneva, Switzerland, 3–10 July 1989;
World Health Organization: Geneva, Switzerland, 1990; Volume 804, pp. 1–75.
12. Hjermstad, M.J.; Kolflaath, J.; Løkken, A.; Hanssen, S.B.; Normann, A.P.; Aass, N. Are emergency admissions in palliative cancer
care always necessary? Results from a descriptive study. BMJ Open 2013, 3, e002515. [CrossRef]
13. Arias-Casais, N.; Garralda, E.; Rhee, J.Y.; Lima, L.; Pons, J.J.; Clark, D.; Hasselaar, J.; Ling, J.; Mosoiu, D.; Centeno, C. EAPC Atlas
of palliative care in Europe 2019; EAPC Press: Vilvoorde, Belgium, 2019; pp. 1–189.
14. Bhalerao, S.; Kadam, P. Sample size calculation. Int. J. Ayurveda Res. 2010, 1, 55. [CrossRef]
15. Sleeman, K.; de Brito, M.; Etkind, S.; Nkhoma, K.; Guo, P.; Higginson, I.J.; Gomes, B.; Harding, R. The escalating global burden of
serious health-related suffering: Projections to 2060 by world regions, age groups, and health conditions. Lancet Glob. Health 2019,
7, e883–e892. [CrossRef]
Int. J. Environ. Res. Public Health 2022, 19, 15204 12 of 12

16. Fischer, S.M.; Gozansky, W.S.; Sauaia, A.; Min, S.-J.; Kutner, J.S.; Kramer, A. A Practical Tool to Identify Patients Who May Benefit
from a Palliative Approach: The CARING Criteria. J. Pain Symptom Manag. 2006, 31, 285–292. [CrossRef] [PubMed]
17. Howie, L.; Peppercorn, J. Early palliative care in cancer treatment: Rationale, evidence and clinical implications. Ther. Adv. Med.
Oncol. 2013, 5, 318–323. [CrossRef] [PubMed]
18. Qureshi, D.; Tanuseputro, P.; Perez, R.; Pond, G.R.; Seow, H.-Y. Early initiation of palliative care is associated with reduced late-life
acute-hospital use: A population-based retrospective cohort study. Palliat. Med. 2019, 33, 150–159. [CrossRef] [PubMed]
19. Barbera, L.; Taylor, C.; Dudgeon, D. Why do patients with cancer visit the emergency department near the end of life? CMAJ
2010, 182, 563–568. [CrossRef]
20. Henson, L.; Higginson, I.J.; Daveson, B.; Ellis-Smith, C.; Koffman, J.; Morgan, M.; Gao, W. ‘I’ll be in a safe place’: A qualitative
study of the decisions taken by people with advanced cancer to seek emergency department care. BMJ Open 2016, 6, e012134.
[CrossRef]
21. Earle, C.C.; Park, E.R.; Lai, B.; Weeks, J.C.; Ayanian, J.Z.; Block, S. Identifying Potential Indicators of the Quality of End-of-Life
Cancer Care From Administrative Data. J. Clin. Oncol. 2003, 21, 1133–1138. [CrossRef] [PubMed]
22. Aksoy, H.; Kahveci, R.; Döner, P.; Aksoy, I.; Ayhan, D.; Koç, E.M.; Şencan, I.; Kasım, I.; Özkara, A. Physicians’ attitudes toward
home healthcare services in Turkey: A qualitative study. Eur. J. Gen. Pract. 2015, 21, 246–252. [CrossRef]
23. Brink, P.; Partanen, L. Emergency Department Use among End-Of-Life Home Care Clients. J. Palliat. Care 2011, 27, 224–228.
[CrossRef]
24. Hoare, S.; Kelly, M.; Prothero, L.; Barclay, S. Ambulance staff and end-of-life hospital admissions: A qualitative interview study.
Palliat. Med. 2018, 32, 1465–1473. [CrossRef]
25. Borraccino, A.; Campagna, S.; Politano, G.; Dalmasso, M.; Dimonte, V.; Gianino, M.M. Predictors and trajectories of ED visits
among patients receiving palliative home care services: Findings from a time series analysis (2013–2017). BMC Palliat. Care 2020,
19, 1–9. [CrossRef]
26. Burge, F.; Lawson, B.; Johnston, G. Family Physician Continuity of Care and Emergency Department Use in End-of-Life Cancer
Care. Med. Care 2003, 41, 992–1001. [CrossRef] [PubMed]
27. Brumley, R.; Enguidanos, S.; Jamison, P.; Seitz, R.; Morgenstern, N.; Saito, S.; McIlwane, J.; Hillary, K.; Gonzalez, J. Increased
Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care. J. Am. Geriatr. Soc. 2007,
55, 993–1000. [CrossRef]
28. Cornillon, P.; Loiseau, S.; Aublet-Cuvelier, B.; Guastella, V. Reasons for transferral to emergency departments of terminally ill
patients-a French descriptive and retrospective study. BMC Palliat. Care 2016, 15, 1–8. [CrossRef] [PubMed]
29. Ali, A.A.; Adam, R.; Taylor, D.; Murchie, P. Use of a structured palliative care summary in patients with established cancer is
associated with reduced hospital admissions by out-of-hours general practitioners in Grampian: Table 1. BMJ Support. Palliat.
Care 2013, 3, 452–455. [CrossRef] [PubMed]
30. Grudzen, C.R.; Richardson, L.D.; Hopper, S.S.; Ortiz, J.M.; Whang, C.; Morrison, R.S. Does Palliative Care Have a Future in the
Emergency Department? Discussions With Attending Emergency Physicians. J. Pain Symptom Manag. 2011, 43, 1–9. [CrossRef]
31. Seow, H.; Brazil, K.; Sussman, J.; Pereira, J.; Marshall, D.; Austin, P.C.; Husain, A.; Rangrej, J.; Barbera, L. Impact of community
based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: A
pooled analysis. BMJ 2014, 348, g3496. [CrossRef]
32. WHO. Why Palliative Care Is an Essential Function of Primary Health Care; World Health Organization: Geneva, Switzerland, 2018.