Palliative Care for Cancer Patients in Emergency Wards

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DESCRIPTION (provided by applicant): Of 28,777 patients 65 yrs or more who died within a year of a diagnosis of lung, breast, or gastrointestinal cancer, >9% had one or more Emergency Department (ED) visits in the last month of life. Many cancer patients also have an ED visit for a cancer-related issue long before their final days. There were 2.1 million cancer-related visits to the ED in the United States between 1997 and 2000. Cancer patients who visit the ED have a high symptom burden, with, on average, over the midway mark on common symptom severity scales. ED's are a refuge for cancer patients in the event of acute exacerbation of symptoms or illness. This is especially so for those of minority status. However, emergency medicine (EM) clinicians have minimal palliative care training. Cancer patients' care goals are often needlessly redirected during an ED visit, and symptoms remain needlessly uncontrolled. Therefore, consistent with the Institute of Medicine and the National Cancer Policy Board's call for the integration of palliative care for patients with cancer and other diseases, we will create: 1. a curriculum-driven, train-the-trainer emergency oncology palliative care education program, and 2. extend its impact in two strategic sites by coupling it with clinical practice reminders linked to curriculum learning objectives. We will evaluate the program's impact on attitudes, knowledge and skills as well as dissemination. For the second part we will also evaluate its impact on clinical behaviors and patient-related clinical outcomes. The program will be modeled on the high-impact Education on Palliative & End-of-life Care (EPEC) Project, and will be called the EPEC-EM Project. Dissemination will be by creation, in partnership with EM specialty associations, of 65 physician and 65 nurse EPEC-EM Trainers. Trainers will be recruited through merit- selected application from EM residency program directors and their program nurse. Trainers will then teach colleagues from their own ED and others beyond their institution, to reach approximately 9,795 end users. We will then provide EPEC-EM education coupled with the clinical reminders, creating one comprehensive intervention to 'blanket' the EDs at the Northwestern Memorial Hospital and Emory's Crawford Long Memorial Hospital. This education+reminders intervention will use an interrupted time-series design. This portion of the project allows us to extend the usual education evaluation to include not only improvement in clinicians' attitudes, knowledge and some skills, but also in clincial behaviours and patient outcomes.