Medical Manuscript

American Journal of Hospice

& Palliative Medicine®
Palliative Care and Rapid Emergency 1-7
ª The Author(s) 2020
Article reuse guidelines:
Screening Tool and the Palliative sagepub.com/journals-permissions
DOI: 10.1177/1049909120960713
Performance Scale to Predict Survival journals.sagepub.com/home/ajh

of Older Adults Admitted to the Hospital

From the Emergency Department

Jonas R. Te Paske, MD1 , Sarah DeWitt, MD1,2, Robin Hicks, DO1,3,

Shana Semmens, MD1,4, and Leigh Vaughan, MD1

Abstract
Background: The Palliative Care and Rapid Emergency Screening (P-CaRES) tool has been validated to identify patients in the
emergency department (ED) with unmet palliative care needs, but no prognostic data have been published. The Palliative
Performance Scale (PPS) has been validated to predict survival based on performance status and separately has been shown to
predict survival among adults admitted to the hospital from the ED. Objective: To concurrently validate the 6-month prognostic
utility of P-CaRES with a replication of prior studies that demonstrated the prognostic utility of the PPS among adults admitted to
the hospital from the ED. Design: Prospective cohort study. Setting/Subjects: Adults >55 years admitted to the hospital from
the ED at an urban academic hospital in South Carolina. Measurement: Baseline PPS score and P-CaRES status were evaluated
within 51 hours of admission. Vital status at 6 months was evaluated by phone or chart review. Results: 131 of 145 participants
completed the study. Six-month survival was 79.2% of those with a PPS of 60-100 (22/106 died) and 48% of those with a PPS of
10-50 (13/25 died) (p ¼ 0.0004). Six-month survival was 85.2% for P-CaRES negative (13/88 died) and 48.8% for P-CaRES positive
(22/43 died) (p < 0.0001). The inferred hazard ratio (HR) for PPS 10-50, as compared to PPS 60-100 was 3.003 (95%CI
(1.475, 6.112) p ¼ 0.0024) and the HR for P-CaRES positive, as compared to P-CaRES negative was 4.186 (95%CI (2.052,
8.536) p < 0.0001). Conclusion: The P-CaRES tool and PPS can predict 6-month survival of older adults admitted from the ED.

Keywords
palliative care, emergency medicine, prognostication, palliative care and rapid emergency screening, Palliative Performance Scale,
PPS

Introduction review of palliative care consultation or referral in the ED

found that interventions in the ED improved quality of life com-
Inpatient palliative care has been associated with increased
pared to usual care, expedited palliative care consultation
patient satisfaction, lower health care costs following discharge,
during admission, and that palliative care in the ED is feasible.6
fewer ICU admissions on hospital readmission, and longer med-
Several studies have demonstrated that ED clinicians
ian hospice stays in a randomized controlled trial.1 As awareness
acknowledge the utility of palliative care in the emergent set-
of the potential benefits of palliative care increased, the Amer-
ting, but that they may benefit from predetermined criteria and
ican College of Emergency Physicians (ACEP) recognized the
mechanisms to initiate palliative care.7,8 In an attempt to
unique opportunity that emergency clinicians have in determin-
ing patients’ trajectory of care and made addressing end of life
care a priority.2,3 As a result, in 2013 the ACEP joined the ABIM 1
Medical University of South Carolina, Charleston, SC, USA
Foundation’s “Choosing Wisely” campaign with the recommen- 2
Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
dation “Don’t delay engaging available palliative and hospice 3
UPMC Pinnacle Health, Harrisburg, PA, USA
care services in the ED for patients likely to benefit.”4 In the time
4
Banner University Medical Center, Tucson, AZ, USA
since that initiative, Grudzen et al. demonstrated in a randomized
Corresponding Author:
clinical trial that emergency department initiated palliative care Jonas R. Te Paske, MD, Medical University of South Carolina, Charleston, SC,
consultation for patients with advanced cancer improved their USA.
quality of life and did not shorten survival.5 A recent systematic Email: [email protected]
2 American Journal of Hospice & Palliative Medicine®

Figure 1. Palliative care and rapid emergency screening tool.

Source: Reference 6, figure 6 (p. 833). Reproduced with permission of Wiley.

facilitate identification of those that might benefit from pallia- identifies if the patient has 2 or more unmet palliative care
tive care consultation, the Palliative Care Rapid Emergency needs and, if so, palliative care consultation is indicated. The
Screening (P-CaRES) tool was developed.9 The P-CaRES tool tool demonstrated content validity, reliability, and acceptabil-
involves 2 steps outlined in Figure 1. The first step identifies if ity to palliative care specialists and emergency medicine clin-
patients have a life-limiting condition. The second step icians.10 A systematic review by George et al. evaluated
Paske et al 3

palliative care screening methods in the ED and proposed sev- Participants

eral characteristics of an optimal screening tool, such as a time
This study was conducted by consideration of all patients
to screen of 1-2 minutes, assessment of functional status, and
admitted through the ED from late September through October
prognostication.11 While numerous methods of prognostication
2017. Potential participants were successively identified via
exist, one of the goals of the current study is to assess if P-
daily reports generated from the electronic medical record
CaRES status itself predicts survival. As a prospective imple-
showing those patients aged 55 or older who had been admitted
mentation of the P-CaRES tool has not yet been published, no
prognostic metrics exist. to the hospital in the prior 24 hours. The potential participant’s
The P-CaRES tool incorporates a component of prognostica- care team was then approached by a co-investigator who con-
tion by asking if the clinician would be surprised if the patient firmed inclusion or exclusion criteria of the patient. Inclusion
died within the following year. However, the P-CaRES tool was criteria consisted of patients age 55 or older and patients with
not specifically designed for prognostication alone, and thus we an admission order for acute or critical care services from the
seek to validate this use with a measure of functional status that ED. Those patients excluded from participation were prisoners,
has been shown to predict survival. The Palliative Performance patients with primary psychiatric diagnosis, patients under
Scale (PPS) was developed by the Victoria Hospice Society in observation status, non-English speaking patients, and those
order to facilitate communication of patient functional status, patients or legal representatives with an inability or unwilling-
provide a useful measure of patient care needs, and for prognos- ness to give informed consent. There was no plan to exclude
tication.12 The PPS was based on the Karnofsky Performance any gender or racial groups. Non-English speaking participants
Scale (KPS) that included assessment of ambulation, activity/ were excluded for practical purposes of not having the funding
extent of disease, and self-care, and then added further functional to support translation services and because their exclusion was
specificity by assessing oral intake and level of consciousness. judged to be unlikely to alter the study endpoints.
The PPS also removed language dependent on patient location, Once the participant was confirmed to meet inclusion cri-
making it applicable across clinical settings. Downing et al. con- teria, a member of the patient’s care team solicited participa-
ducted a systematic reviewed of several studies that demon- tion in a research project to the potential research participant
strated construct validity of the PPS as a prognostic tool by and/or their legal representative. If the participant or their legal
demonstrating a direct ordinal relationship between each PPS representative verbally agreed to consider participation in the
score and patient survival.13 These studies affirmed this relation- study, the co-investigator approached the patient and/or legal
ship across multiple clinical settings including a tertiary hospital presentative, explained the nature of the study, enrolled that
at the time of palliative care consultation, an inpatient palliative participant via written informed consent and then completed
care unit, as well as among outpatient and inpatient hospice the interview for all study items.
patients. More recent studies have supported the use of PPS for
prognostication of a general population of adult patients in the
ED, but they were limited by small sample size and racial homo- Data Collection
geneity.14,15 The PPS benefits from being a more rapid assess-
ment than the P-CaRES tool. The enrollment process consisted first of chart review
The current study seeks to establish survival estimates of followed by an in-person interview by 1 of 3 trained
both P-CaRES positive patients and performance status as co-investigators who were all hospice and palliative medicine
assessed by the PPS. In doing so, we hope to replicate the fellows. The co-investigators screened participants using the
findings demonstrating the prognostic utility of the PPS in the P-CaRES tool (Figure 1) with information gathered from
ED in a more diverse sample, while simultaneously validating chart review or by direct assessment during interview with
the prognostic utility of P-CaRES. Having accurate survival the participant and/or primary caregiver. Detailed instructions
estimates of applicable patient populations would help inform for completing the P-CaRES tool can be found in George
early goals of care conversations, potentially even while still in et al.9 Participants screen positive for palliative care referral
the ED. We hypothesize that P-CaRES positive patients will were defined as P-CaRES positive.
have a significantly decreased survival. Additionally, we The co-investigator then assessed a baseline PPS of the
hypothesize that a decreased PPS will concurrently be associ- participant in the standard manner on a scale from 10 to 100
ated with decreased survival. by asking the participant or their caregiver questions about
their functional capacity, including; ambulation, activity/evi-
dence of disease, self-care, dietary intake, and level of con-
Methods sciousness. The baseline PPS was assessed regarding the
participant’s functional status just prior to the inciting events
Overview of their admission. Participants were defined as having a PPS of
This study is a prospective cohort design that involved patients 10-50 if their functional status was as follows, or worse: mainly
admitted through the ED at an urban academic tertiary care sit/lie, unable to do any work, has extensive disease, and con-
center in South Carolina. The methods were approved by the siderable assistance required for self-care. Finally, the partici-
Institutional Review Board. pant and/or caregiver was asked if they could be contacted by
4 American Journal of Hospice & Palliative Medicine®

phone to repeat PPS questioning at 3 and 6 months after initial Table 1. Life-Limiting Illness That Indicated P-CaRES Positive Score.
data was collected.
Frequency

Follow Up Data Collection Advanced Dementia of CNS Disease 5

Advanced Cancer 14
The participants were called 3 and 6 months after admission to End Stage Renal Disease 8
the hospital to reassess their PPS at that time. Date of death was Advanced COPD 0
assessed by review of the medical record, report of the care- Advanced Heart Failure 11
giver when attempting to contact the patient, and internet End Stage Liver Disease 1
Septic Shock 2
search of obituaries. Patients not confirmed deceased were
Provider Discretion 6
contacted again at 6 months. Those patients not successfully
contacted at either 3 or 6 months were coded as lost to follow-
up and the data censored as of their last confirmed contact The mean age of P-CaRES positive patients was greater than
within the medical record up to 6 months after admission. that of P-CaRES negative status, but not significant when stra-
tified by 10 year groupings. No significant differences by age
Outcomes existed between the 2 PPS groups. P-CaRES status varied sig-
The primary endpoint was 6-month survival after admission to nificantly by PPS. The PPS 60-100 group had a significantly
the hospital. Covariates include age, race, gender, marital sta- higher proportion of patients with P-CaRES negative status
tus, prior hospice or palliative care, PPS score, and P-CaRES than the PPS 10-50 group, and conversely a lower proportion
score. of patients with P-CaRES positive status. Both P-CaRES and
PPS varied significantly by prior hospice or palliative care and
by death at 6 months. The P-CaRES positive and PPS 10-50
Analysis group had significantly higher proportion of patients who had
Participants were grouped by baseline PPS with ranges of 10- received hospice or palliative care compared to the P-CaRES
50 and 60-100. Participants who met criteria for palliative negative and PPS 60-100 group, respectively. The P-CaRES
care consultation according to the P-CaRES tool were cate- positive and PPS 10-50 group had significantly higher mortal-
gorized as P-CaRES positive, in contrast to P-CaRES negative ity rates at 6 months compared to the P-CaRES negative and
for those not meeting criteria. Univariate statistical compar- PPS 60-100 group, respectively.
isons were made using Fisher Exact and Analysis of Variance The multivariable analyses confirmed the significant
(ANOVA) tests. Survival plotting were created using Kaplan- increase in mortality associated with P-CaRES positive (Table
Meier survival technique. A multivariable Cox proportional 3). From this model, the inferred hazard ratio (HR) of P-CaRES
hazard model was used to control for interacting factors of positive, as compared to P-CaRES negative was 4.186 (95%CI
age, gender, race, marital status, PPS Score, and P-CaRES (2.052, 8.536) p < 0.0001), implying that the risk of dying is
status. Separate multivariable cox models were run for PPS roughly 4 times greater for the P-CaRES positive patients than
and P-CaRES as the 2 variables were so highly correlated. the P-CaRES negative patients. In terms of other predictors of
Prior hospice or palliative care status was too correlated with mortality, older aged patients tended to have slightly higher
age, PPS score, and P-Cares score to be included in the multi- mortality rates than younger patients (p ¼ 0.0163). The
variable models. SAS 9.4 (SAS Institute Inc., Cary, NC) was Kaplan-Meier survival curves by P-CaRES grouping are shown
used for statistical analyses. in Figure 2 with survival measured in days from time of admis-
sion to death or up to 180 days. The results are supportive of
Results those from the univariate and multivariable mortality results
Enrollment was conducted from August 2017 through Octo- suggesting that P-CaRES positive patients have higher mortal-
ber 2017. Of the 348 screened for inclusion, 145 participants ity through time.
were enrolled in our study, and 131 were followed to 6 months The multivariable analyses confirmed the significant
or death. Reasons for patients declining participation included increase in mortality associated with the PPS 10-50 group
lack of decision-making capacity and/or legal guardian rep- (Table 4). From this model, the inferred hazard ratio (HR) of
resentation, unmet symptom burden, or simply that they were the PPS 10-50 group, as compared to the PPS 60-100 group was
not interested in participating in a research study. Participants 3.003 (95%CI (1.475, 6.112) p ¼ 0.0024), implying that the
were enrolled a mean of 26.2 hours after admission (SD: 8.7, risk of dying is roughly 3 times greater for the PPS 10-50 group
range 1-51). The frequencies of life-limiting illnesses that than the PPS 60-100 group. Similar to the P-CaRES model,
caused a participant to have a positive P-CaRES are outlined older aged patients tended to have slightly higher mortality
in Table 1. rates than younger patients (p ¼ 0.0036). The Kaplan-Meier
Univariate analysis (Table 2) revealed similar demographics survival curves by PPS group are shown in Figure 3 with sur-
within the 2 P-CaRES statuses (positive and negative) and 2 vival measured in days from time of admission to death or up to
PPS groups (10-50 and 60-100) with only several exceptions. 180 days. The results are supportive of those from the
Paske et al 5

Table 2. Demographics.

P-CaRES positive, P-CaRES negative, PPS 10-50, PPS 60-100,

[n ¼ 43] [n ¼ 88] P value [n ¼ 25] [n ¼ 106] P Value

Age (mean, SD) 72.2 + 11.4 68.3 + 9.2 0.0405 72.4 + 10.5 69.0 + 10.0 0.1301
Age Group (%) 0.0870 0.1713
55-64 23.3 35.2 20.0 34.0
65-74 30.2 35.2 28.0 34.9
75-84 30.2 25.0 44.0 22.6
84þ 16.3 4.6 8.0 8.5
Gender (%) 0.1706 0.1786
Female 60.5 47.7 64.0 49.1
Male 39.5 52.3 36.0 50.9
Race (%) 0.9391 0.9485
White 72.1 72.7 72.0 72.6
Black 27.9 27.3 28.0 27.4
Marital Status (%) 0.4452 0.6324
Unmarried 39.5 46.6 40.0 45.3
Married 60.5 53.4 60.0 54.7
P-CaRES (%) – <0.0001
Negative – – 20.0 78.3
Positive – – 80.0 21.7
Baseline PPS Group (%) <0.0001 –
10-50 46.5 5.7 – –
60-100 53.5 94.3 – –
Ever been a hospice or palliative care patient (%) 32.6 1.1 <0.0001 32.0 6.6 0.0016
Death at 6 month (%) 51.2 14.8 <0.0001 52.0 20.8 0.0015

P-CaRES: Palliative Care and Rapid Emergency Screening, PPS: Palliative Performance Scale.

Table 3. Survival Analysis Model Results (P-CaRES as Primary days and 122 days for those who were P-CaRES positive. Increas-
Covariate). ing age independently predicted 6 month mortality, but there were
no differences in PPS groups by race, gender, marital status.
Hazard Lower Upper
Ratio (HR) HR HR P Value
The prior studies of PPS for prognostication of ED patients
had limited generalizability because of racial homogeneity.14,15
Age 1.038 1.007 1.07 0.0163 A benefit of our study was that it was conducted at an urban
Black 0.656 0.26 1.658 0.3731 academic medical center where the rate of black participants
Female 0.983 0.492 1.966 0.9619 more closely mirrored the state percentages than Babcock et al.
Married 0.848 0.399 1.802 0.6677
(27.5% vs 29.7% in SC compared to 4.9% vs 12.0% in CT)14
P-CaRES positive (Ref. 4.186 2.052 8.536 <0.0001
negative) This point is noteworthy because minorities have been shown
to have lower quality care near the end of life in regard to pain
P-CaRES: Palliative Care and Emergency Screening. management and satisfaction with care and clinician
communication.16
univariate and multivariable mortality results suggesting that Baseline PPS and P-CaRES status were too closely corre-
PPS 60-100 groupings have lower mortality through time. lated to be able to evaluate their utility in predicting survival in
combination compared to either measure individually. Never-
theless, our demonstration that the P-CaRES tool and PPS are
Discussion highly correlated in their prediction of 6 month survival sup-
Our findings demonstrate that lower baseline PPS scores are pre- ports the concurrent validity of P-CaRES tool prognostication
dictive of death within 6 months, which is in agreement with prior with that of the previously validated PPS. We found that they
studies of this clinical setting.14,15 Specifically our data suggest are both helpful in identifying those at increased risk of dying
that patients who, at most, mainly sit or lie and are unable to do within 6 months, but they have their own utility. P-CaRES is
any work at baseline (PPS 50) are 3 times more likely to die validated for identifying those patients with pre-existing con-
within 6 months compared to those less debilitated. Similarly, ditions who have significant unmet palliative care needs and
patients meeting criteria for inpatient palliative care consultation thus may facilitate ED clinicians to initiate primary or specialty
based on the P-CaRES tool were 4 times more likely to die within palliative care. Our study now demonstrates that those patients
6 months compared to those not meeting criteria. The median screened positive by P-CaRES have decreased survival, a fact
survival for patients with a baseline PPS of 50 or less was 110 that may facilitate goals of care conversation. Future studies
6 American Journal of Hospice & Palliative Medicine®

P-CaRES No. of Median Survival PPS No. of Median Survival

Status Subject Event Censored (95% CI) Group Subject Event Censored (95% CI)

Negative 88 13 (14.8%) 75 (85.2%) NA (NA, NA) 10-50 25 13 (52.0%) 12 (48.0%) 110 (49, NA)
Positive 43 22 (51.2%) 21 (48.8%) 122 (74,NA) 60-100 106 22 (20.8%) 84 (79.2%) NA (NA,NA)

P-CaRES: Palliative Care and Rapid Emergency Screening. PPS: Palliative Performance Scale.

Figure 2. Kaplan-Meier plot by P-CaRES status. Figure 3. Kaplan-Meier plot by PPS group.

Table 4. Survival Analysis Model Results (PPS as Primary Covariate). Limitations

Hazard Lower Upper Limitations of the current study are that it only includes a single
ratio (HR) HR HR P value site and enrollment occurred over a 6-week period and thus is
Age 1.049 1.016 1.083 0.0036 subject to site specific and time of year bias, respectively. In
Black 0.708 0.287 1.749 0.4541 addition, 3 different co-investigators collected data and there
Female 1.034 0.525 2.035 0.9236 was no assessment of intra-rater reliability. While PPS score
Married 0.866 0.412 1.820 0.7041 assessment is inherently subjective, high inter-rater reliability
PPS Score 10-50 Group (Ref. 60- 3.003 1.475 6.112 0.0024 has been demonstrated previously17 and all 3 co-investigators
100)
were hospice and palliative medicine fellows and had received
PPS: Palliative Performance Scale. training in PPS assessment. Baseline PPS requires assessment
of the patient’s functional status prior the inciting event of their
could expand the concurrent prognostic validity of P-CaRES hospital admission and thus is subject to patient or caregiver
by combining assessment with disease specific prognostic tools recall bias. The P-CaRES tool is less subjective and pilot data
(FAST scale in dementia patients, GO-FAR tool for in-hospital demonstrated high inter-rater reliability.10 However, P-CaRES
cardiac arrest). was designed for assessment in the ED and thus may also be
While the PPS cannot identify specific unmet needs, it does less valid in the current setting where participants were
have the advantage of being a more rapid assessment tool and assessed an average of 26 hours after admission. The study was
ED clinicians may consider using the PPS scale alone to aid in designed in this manner because we could not staff the ED
their prognostication based on our findings. To further simplify throughout the entirety of the study period nor was their suffi-
the categorization of those patients with a PPS of 50 or less, this cient staff to assess the numerous patients being evaluated in
group may be identified by a single question of the following, the ED prior to confirmation of admission. Our design allowed
“At baseline, do you normally sit or lie down during the day, us to assess only those patients requiring admission and
and are unable to do any kind of work?” Furthermore, in other ensured that over the study period all such consecutive patients
settings a PPS of 10 has been shown to predict survival to just were considered for inclusion to limit selection bias. As with
several days13 and thus may have more specificity in identify- prior studies exploring the use of PPS to predict survival after
ing those who might benefit from direct referral to hospice and hospital admission from the ED, the current study is limited by
forego admission. Future studies are needed to further evaluate small sample size, which prevented stratification of survival by
this method of assessment. each level of the PPS.
Paske et al 7

Conclusions singwisely.org/clinician-lists/american-college-emergency-physi
cians-delaying-palliative-and-hospice-care-services-in-emer
In addition to identifying patients with unmet palliative care
gency-department/
needs who might benefit from an inpatient palliative care con-
5. Grudzen CR, Richardson LD, Johnson PN, et al. Emergency
sultation, the P-CaRES tool can predict 6 month survival and is
department–initiated palliative care in advanced cancer: a rando-
highly correlated with prognostication using the PPS. Future
mized clinical trial. JAMA Oncol. 2016;2(5):591-598.
randomized clinical trials of P-CaRES tool implementation
6. Wilson JG, English DP, Owyang CG, et al. End-of-life care,
with larger sample size are needed to confirm the findings of
palliative care consultation, and palliative care referral in the
our prospective cohort.
emergency department: a systematic review. J Pain Symptom
Authors’ Note Manage. 2020;59(2):372-383.e1.
7. Grudzen CR, Hwang U, Cohen JA, Fischman M, Morrison RS.
The views expressed in this manuscript are the authors alone and not
an official position of the authors’ respective institutions. Preliminary Characteristics of emergency department patients who receive
findings were presented by S. DeWitt as a poster presentation at the a palliative care consultation. J Palliat Med. 2012;15(4):
American Academy of Hospice and Palliative Medicine Annual 396-399.
Assembly in Orlando, Florida, from March 13-16, 2019. 8. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care
provision in the emergency department: barriers reported by
Acknowledgments emergency physicians. J Palliat Med. 2013;16(2):143-147.
The authors thank Patrick Maudlin, PhD, and Jingwen Zhang, MS, for 9. George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J.
their statistical support. Content validation of a novel screening tool to identify emergency
department patients with significant palliative care needs. Acad
Declaration of Conflicting Interests
Emerg Med. 2015;22(7):823-837.
The authors declared no potential conflicts of interest with respect to 10. Bowman J, George N, Barrett N, Anderson K, Dove-Maguire K,
the research, authorship, and/or publication of this article.
Baird J. Acceptability and reliability of a novel palliative care
Funding screening tool among emergency department providers. Acad
Emerg Med. 2016;23(6):694-702.
The authors received no financial support for the research, authorship,
and/or publication of this article. 11. George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C.
Palliative care screening and assessment in the emergency depart-
ORCID iD ment: a systematic review. J Pain Symptom Manage. 2016;51(1):
Jonas R. Te Paske https://orcid.org/0000-0001-8718-8621 108-119.e2.
12. Anderson F, Downing GM, Hill J, Casorso L, Lerch N. Palliative
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