Advance directives, hospitalization, and survival among advanced cancer patients with deliriumpresenting to the emergency department: A prospective study

Background. To improve the management of advanced cancer patients with delirium in an emergency department (ED) setting, we compared outcomes between patients with delirium positively diagnosed by both the Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS), or group A (n522); by the MDAS only, or group B (n522); and by neither CAMnorMDAS, or group C (n5199). Materials and Methods. In an oncologic ED, we assessed 243 randomly selected advanced cancer patients for delirium using the CAM and the MDAS and for presence of advance directives. Outcomes extracted from patients’ medical records included hospital and intensive care unit admission rate and overall survival (OS). Results. Hospitalization rates were 82%, 77%, and 49% for groups A, B, and C, respectively (p5.0013). Intensive care unit rates were 18%, 14%, and 2% for groups A, B, and C, respectively (p5.0004). Percentages with advance directives were 52%, 27%, and 43% for groups A, B, and C, respectively (p5.2247). Median OS was 1.23 months (95% confidence interval [CI] 0.46–3.55) for group A, 4.70 months (95% CI 0.89–7.85) for group B, and 10.45 months (95% CI 7.46–14.82) for group C. Overall survival did not differ significantly between groups A and B (p5.6392), but OS in group C exceeded those of the other groups (p< .0001 each). Conclusion. Delirium assessed by either CAM or MDAS was associated with worse survival and more hospitalization in patients with advanced cancer in an oncologic ED. Many advanced cancer patients with delirium in ED lack advance directives. Delirium should be assessed regularly and should trigger discussion of goals of care and advance directives.