Crash Cart: The decrease in ED deaths, complicated science papers, and telling patients the bad prognosis

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This week: Studies show there has been a substantial drop in ED deaths since 2011. Plus, when is the right time to tell your patient’s family the bad prognosis? Join in as our editors discuss the week’s headlines.

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ED deaths dropped 48% since 2011

The decline in ED mortality may be due to advances in critical care and enhanced training of prehospital personnel. Original Article by Medscape.

Nicholas Genes, MD, PhD: While I would love to pat all of us on the back for taking better care of patients, the authors give a bevy of plausible explanations why the ED death rate has declined, besides just “we’re better at emergencies.” They suggest it may be due to increased palliative care and DNR/DNI orders, better access to ED care before critical illness, improved field resuscitation termination guidelines, and so on. The idea that we’re keeping them alive until they die as inpatients is also considered – but inpatient deaths have remained static in recent years. Whenever someone looks at vague, mysterious NHAMCS data there’s always more questions – hopefully future ED registries will give more insight.

William Sullivan, DO, JD: Not only did deaths in the emergency department decrease, but of the patients dying in the emergency department, 62% arrived unconscious, in full arrest, or dead on arrival –  which shouldn’t be blamed on emergency department care. Or maybe I should say shouldn’t be “attributed to” emergency department care. In addition 58% of patients who died were over age 65 and 28% were over age 80. A couple of other interesting statistics from the study: Of 366,000 visits, only 974 patients died in the emergency department. We hear a lot about the risk of “bouncebacks,” but of the 974 patients dying in the ED, less than 30 were known to have been in the same ED within the past 3 days and less than 30 were discharged from the hospital within the prior week. Also of note is that emergency department use by both Medicaid and Medicare patients is rising substantially. After reading the headlines about the study’s conclusions that ED deaths dropped by nearly 50%, the first thing that popped into my head was “there are so many ways you can spin these results.” The authors and Nick also picked up upon this. Emergency departments are going to say that “it’s because we’re providing outstanding care.” Hospital administrators are going to say “it’s because we’re providing outstanding care and we’re moving patients through the department faster.” Hospices will say “it’s because we’re better able to provide compassionate care at home.” Conspiracy theorists are somehow going to blame “death panels”. Researchers are going to say “we need more research to determine why.” Fast forward to the study conclusion: “Further research is needed to delineate the underlying causative factors.” Heh. All I know is that I’m going to keep providing outstanding care.

Ryan McKennon, DO: 55% reduction sounds like a huge number. In actual terms though the difference is less than 1 in every 2000 adults. I think greater hospice utilization probably plays a large role here, as has improved care. According to the world bank, the mortality rate in the US has dropped by almost 1 in 1000 during the corresponding time period. This alone probably could explain the entire reduction, as much as I would like to attribute it to our care.

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Science publishing is complicated; ScienceMatters aims to demystify the process

As a new initiative, ScienceMatters makes it easy for researchers to publish single observations without delay. Original Article by Stat News. // Accompanying Study by PLOS.

Nicholas Genes, MD, PhD: Always nice to see what Ivan Oransky is writing about – but this paper quantifies a phenomenon we’ve suspected is true for some time. I remember in college being vaguely disturbed that achievements that would’ve merited a paper in the past, like sequencing a plasmid, had become just a paragraph in the “methods” section of then-current papers. I do like the idea of ScienceMatters though, like open-access journals, publishing observations bereft of a “story” can hurt careers, or be gamed. It’s too bad that something so rational as science is still subject to so many human foibles.

William Sullivan, DO, JD: Sorry, but a complex paper with multiple complex graphs and 53 citations telling me how scientific publishing has become too complex over the past two decades is waaaay too ironic for me. I read through the abstract, nodded my head a couple of times and clicked out. I like the idea of ScienceMatters, as mentioned in the article, though. Not only are the articles on the site short, but they aren’t behind a paywall and they get ratings from peer reviewers who are reportedly “triple blinded” during their review. Hopefully the site doesn’t become like a scientific Yelp. That would be a shame.

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End of life care: When do you tell your patient’s family the bad prognosis?

Oftentimes doctors hesitate to discuss a poor prognosis with patients and their families. Original Article by The New York Times.

Nicholas Genes, MD, PhD: Well, this certainly helps explains a lot of ED visits, where family expectations for survival seem wildly discordant with even a cursory assessment of the patient. I find myself, in the ED, often taking the other side – I don’t know much but say quite a bit. I just met the patient, after all – but try to express to the family that, to me, this patient sure looks sick, and has advanced cancer or other conditions that make recovery a long shot. Sometimes families are surprised by my candor, sometimes put off by it  – but many times they seem a bit relieved, because they can sense what’s happening too and are just looking for some validation.

William Sullivan, DO, JD: It’s nice to try to bookend how much time someone has left, but it isn’t that easy. I routinely hear patients and families talk with disdain about doctors who told them that mom only had “six months to live – and that was THREE YEARS ago”. A doctor may know that someone has advanced cancer, but there is no way to tell how well the patient will respond to treatment or even IF the patient will respond to treatment. In many cases, physicians are simply not as good as people think at estimating prognosis. Besides, I’ve had complaints to administrators and gotten Press Ganey nastygrams for suggesting that based upon my assessment of a patient, the patient may no longer be capable of living at home alone. I can only imagine what vitriol is sometimes generated when families are unexpectedly told that a family member has a terminal diagnosis. There’s a lot more to holding back opinions than doctors only wanting to be “cheerleaders” or wanting to give patients a rosy picture of recovery so they won’t stop paying for chemotherapy. Apparently further research is needed to delineate the underlying causative factors.

Ryan McKennon, DO: I agree with Bill, we are just not that good as giving an accurate prognosis in regards to how much time someone has to live in most cases. The article cites a family member who said he was “only asking for your opinion, not a guarantee.” Although not intentionally, I believe most family members would take it as a guarantee, or be at least be angry if the physician was off in either direction. This can be especially difficult in the ED; for example, the tragic cases of a new diagnosis of metastatic CA unexpectedly found throughout the abdomen on a CT scan. We know the prognosis is bad, but days? weeks? months? years? This depends on so many factors including the type of cancer obviously not known at the time. So, we hedge. It is important though that we give an honest and accurate assessment of the clinical picture. Maybe in the future I will try a be a little less “hedgy.”

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