The present study shows the influence of our palliative care team during the last six months of life with regard to reducing the number of emergency calls by palliative cancer patients and their relatives. Therefore, the study approaches the important issue of whether and how our palliative care team could prevent unnecessary hospital admissions towards the end of life.
Approximately 3–4% of all emergency calls are for palliative patients in the final stages of their disease [[8, 17], and ]. Most of these calls were placed while the patients and their care-giving relatives had no access to a palliative care team . The present survey showed that most emergency calls in the last six months of the terminally ill patients' lives were placed before the patient was in the care of our palliative care team (91% vs. 9%). Thirty-five of the patients had been in the care of the palliative care team for less than six months. None of the eleven patients who had been seen by the palliative care team for more than six months placed an emergency call. This finding suggests that emergency medical services tend to be called in less frequently if the patient and the caregiving relatives can have the continuous and always available support by competent palliative caregivers. In the present investigation, only two (9%) of the emergency calls were placed while the patients had access to the palliative care team.
Acute situations can arise in the end-of-life phase of palliative patients that require a prompt reaction. In the final stage of cancer disease, symptoms can exacerbate or new, acute problems can arise that emphasize the dynamics of the disease process . Caregiving relatives can be under great physical and psychological strain in such an acute situation. Therefore, this psychosocial strain can be overwhelming and can induce the caregiver to call the emergency medical service when what they actually want is advice and someone to talk to in a situation they experience as threatening and confusing. One should not ignore the fact that life-threatening situations can occur (e.g. acute hemorrhage, suffocation) that do require immediate medical attention. However, symptoms usually worsen gradually, giving time to make contingency plans. Due to their state of overwhelming psychological strain the caregivers are often unable implement and follow these plans. On the other hand, some symptoms cannot be dealt with at home under the best of circumstances.
The following structural approaches for improving the emergency medical care of palliative care outpatients are under discussion:
Early studies also show that most emergency calls are made by or for patients, for whom outpatient palliative care is not available [8, 10]. The results of the present study support these findings. The merit of continuous support during the end-of-life with regard to the frequency of emergency calls has also been reported by other investigators . When these services are unavailable, the caregiving family members are left on their own, and this often leads to overstrain and a lack of cooperation. Emergency physicians on the scene have to decide on the spot without knowledge of the patient's wishes and existing contingency plans or therapy restrictions. For this reason it is essential to integrate palliative medical topics into the curriculum for emergency medicine to ensure patient-oriented therapy [[8, 9, 17, 20, 21] and ]. In Germany, this might mean including topics from the specialty training guidelines for palliative medicine described in the regulations for further training set forth by the German Medical Association in the requirements for the specialty of emergency medicine .
On the other hand, it is eminently important to recruit professional palliative medical assistance at an early stage of the disease, as this can positively influence the fulfillment of the patient's wishes in the final stage of their disease [10, 11].
A further possibility for improving the emergency care of palliative outpatients is to integrate a palliative care team into the primary alert structure of the emergency medical service at the level of the dispatcher [11, 23]. The idea of this would be that a palliative care team would be alerted at the time of an emergency call from caregivers of palliative patients as part of the primary response. The palliative care team could then visit the patient at his home. The key word for the dispatcher might be "cancer patient", "palliative care patient" or "hospice patient". A second alternative would be for the emergency medical service primarily seeing the patient to alert the palliative care team who would then take over the outpatient care. A study of this model in France showed that there was a significant reduction in the number of hospital admissions [11, 23].
Measures should be initiated within the ambulatory care organizations aimed at eliminating the information gaps often encountered in the care of patients with life-threatening disease. In this context, it has been suggested that emergency plans be prepared [8, 17] or that a copy of the patient's medical file be left with the patient  in order to provide the emergency physician treating the patient in the acute situation with information on the disease, its course and therapy decisions. Closing information gaps is considered to be pivotal in improving medical care at the end of life, since inappropriate decisions at this point are often the result of information deficits [22, 26].
Apart from the influence of pertinent information on therapy decisions in emergency situations, another successful measure has been to supply the patient with an emergency medicine chest containing medications that he might require in an acute situation. The caregiving relatives are trained to administer the medications in precisely defined situations in order to act according to the patient's wishes and alleviate symptoms and suffering in the acute situation . One could object to this practice on the grounds that it is exactly in such extraordinary situations that the relatives do not follow or are unable to follow the therapy plans laid out and agreed upon beforehand. Further studies are necessary to determine which factors determine success and failure.
A further way to ensure that medical care follows the will and wishes of the patient is to draw up an advance directive, give instructions for critical situations, such as a "Do not attempt resuscitation" (DNAR) order, and to grant power of attorney. This can assist the emergency physician in his treatment decisions [[8, 23, 27], and ]. Correctly worded and presented at the proper moment, these can have a decisive influence on the patient's further treatment . Outpatient care by a palliative care team would not only reduce the frequency of emergency calls by patients on palliative care, but it would also have the effect that patients would not have to be admitted to the hospital and could remain in their homes to die as they wished .
A secondary effect of these structural approaches is that a therapy concept adapted to the wishes of the patient does not have to be abandoned due to emotional exhaustion of the caregiver, since the latter has been shown to be one of the primary reasons for contacting the emergency medical service [[8, 31], and ]. This kind of stressful situation, which can overstrain the caregiver and thereby trigger irrational decisions, will be intensified by a lack of adequate outpatient support [[11, 23, 31], and ]. A palliative care team like the one participating in this study, which is available 24 hours every day, can contribute to keeping the patient in his domestic environment for therapy and care even in critical situations. By continuously supporting the caregivers and preparing them for acute events, one can often reduce the impact of and put into perspective the situations that might otherwise have led them to make an emergency call. This cannot always prevent palliative medical emergencies, but their effects on patient-oriented care can be attenuated. This is reflected by the assessment of 29 of the interviewed family members (63%), who stated that care of the patient would not have been possible at home without the support of our palliative care team.
The acute situations described in the present study placed an overwhelming strain on the relatives, which led them to call the emergency medical service. Critical situations also arose during the time the patients were being cared for by our palliative care team, but the psychological burden of the caregiving relatives was markedly reduced. The MCS-12 scores were significantly lower amongst the caregiving relatives of cancer patients indicating greater mental strain compared to the general population . A comparison with published data showed that family members who had the support of our palliative care team tended to be under less mental strain than those who cared for tumor patients without support of the palliative care team . However, the present study did not show any connection between low MCS-12 scores of the caregivers and the likelihood of their placing an emergency call. The relevance of the measured MCS-12 scores for predicting the likelihood of an emergency call is questionable, since they were determined retrospectively some considerable time after the emergency situation. One might conclude from the significantly lower frequency of emergency calls after institution of support by the palliative care team that this support had also led to a reduction of the psychological burden on the caregivers. The fact that critical situations and with them reasons for calling the emergency medical service occur more often during the final stages of the disease [19, 33] lends additional weight to this observation.
The reasons for calling the emergency medical service found in the present survey were the same frequently given in other studies of palliative care patients [8, 19, 34–37]. Therefore, the findings of this investigation seem to be generalisable.