title: Emergency Department-Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial.
abstract: OBJECTIVE
  The delivery of palliative care is not standard of care within most emergency departments (EDs).
  
  
  OBJECTIVE
  To compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual.
  
  
  METHODS
  A single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization.
  
  
  METHODS
  Intervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care.
  
  
  METHODS
  The primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year.
  
  
  RESULTS
  A total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice.
  
  
  CONCLUSIONS
  Emergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01358110.
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Corita R
authors.initials: CR
authors.lastname: Grudzen
authors.affiliation: The Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Lynne D
authors.initials: LD
authors.lastname: Richardson
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Pauline N
authors.initials: PN
authors.lastname: Johnson
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Ming
authors.initials: M
authors.lastname: Hu
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Binhuan
authors.initials: B
authors.lastname: Wang
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Ortiz
authors.affiliation: The Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Emmett A
authors.initials: EA
authors.lastname: Kistler
authors.affiliation: Rutgers-Robert Wood Johnson Medical School, New Jersey.
authors.forename: Angela
authors.initials: A
authors.lastname: Chen
authors.affiliation: The Icahn School of Medicine at Mount Sinai, New York, New York4James J. Peters VA Medical Center, Bronx, New York.
authors.forename: R Sean
authors.initials: RS
authors.lastname: Morrison