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Kim K, Chakravarthy B, Anderson C, Liao S. To Intubate or Not to Intubate: Emergency Medicine Physicians' Perspective on Intubating Critically Ill, Terminal Cancer Patients. J Pain Symptom Manage 2017; 54:654-660.e1. [PMID: 28754440 DOI: 10.1016/j.jpainsymman.2017.07.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/15/2017] [Accepted: 07/18/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT Emergency physicians (EPs) often need to make a decision whether or not to intubate a terminal cancer patient. OBJECTIVE The objective of this study was to explore EPs' attitudes about intubating critically ill, terminal cancer patients. METHODS Fifty EPs at three emergency departments (one university based, one community, and one Health Maintenance Organization) in Southern California participated in an anonymous survey that presented a hypothetical case of an end-stage lung cancer patient in pending respiratory failure. Fourteen questions along a five-point Likert scale asked EPs about prognosis and factors that influence their decision to intubate or not. RESULTS A convenience sampling of 50 EPs yielded a 100% survey response rate. Ninety-four percent believed intubation would not provide an overall survival benefit. If the family insisted, 26% would intubate the patient even with a do-not-intubate (DNI) status. Ninety-four percent would postpone intubation if palliative consultation were available in the ED. Sixty-eight percent believed that a discussion about goals of care was more time consuming than intubation. Only 16% believed they had sufficient training in palliative care. Although 29% who felt they had inadequate palliative care training would intubate the patient with a DNI, only 13% of EPs with self-perceived adequate palliative care training would intubate that patient. CONCLUSION EPs vary in their attitudes about intubating dying cancer patients when families demanded it, even when they believed it was nonbeneficial and against the patient's wishes. Palliative care education has the potential to influence that decision making. Intubation could be mitigated by the availability of palliative consultation in the ED.
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Affiliation(s)
- Kenneth Kim
- Department of Palliative Medicine, University of California, Irvine, California, USA.
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Craig Anderson
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Solomon Liao
- Department of Palliative Medicine, University of California, Irvine, California, USA
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Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral. J Emerg Med 2017; 54:191-197. [PMID: 28988735 DOI: 10.1016/j.jemermed.2017.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/22/2017] [Accepted: 08/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease. OBJECTIVES To investigate the effectiveness of our AI Management program in the ED on key outcomes. METHODS We conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate. RESULTS Our sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001). CONCLUSIONS The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.
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Cotogni P, De Luca A, Saini A, Brazzi L. Unplanned hospital admissions of palliative care patients: a great challenge for internal and emergency medicine physicians. Intern Emerg Med 2017; 12:569-571. [PMID: 28477288 DOI: 10.1007/s11739-017-1671-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/25/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
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Lederman Z, Baird G, Dong C, Leong BSH, Pal RY. Attitudes of Singapore Emergency Department staff towards family presence during cardiopulmonary resuscitation. ACTA ACUST UNITED AC 2017. [DOI: 10.1177/1477750917706175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zohar Lederman
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Geraldine Baird
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | - Chaoyan Dong
- Sneaking Health, SingHealth, Singapore, Singapore
| | - Benjamin SH Leong
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | - Rakhee Y Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
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Weng TC, Yang YC, Chen PJ, Kuo WF, Wang WL, Ke YT, Hsu CC, Lin KC, Huang CC, Lin HJ. Implementing a novel model for hospice and palliative care in the emergency department: An experience from a tertiary medical center in Taiwan. Medicine (Baltimore) 2017; 96:e6943. [PMID: 28489813 PMCID: PMC5428648 DOI: 10.1097/md.0000000000006943] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.
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Affiliation(s)
| | | | - Ping-Jen Chen
- Palliative Care Center, Chi-Mei Medical Center
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Department of Geriatrics and Gerontology, Chi-Mei Medical Center, Tainan
| | | | | | - Ya-Ting Ke
- Department of Nursing
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Graduate Institute of Nursing, Kaohsiung Medical University, Kaohsiung
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology
| | - Kao-Chang Lin
- Holistic Care Unit, Department of Internal Medicine
- Department of Biotechnology, Southern Taiwan University of Science and Technology
| | - Chien-Cheng Huang
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Department of Geriatrics and Gerontology, Chi-Mei Medical Center, Tainan
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University
- Department of Occupational Medicine, Chi-Mei Medical Center, Tainan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology
- Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
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ED Utilization and Self-Reported Symptoms in Community-Dwelling Older Adults. J Emerg Nurs 2017; 43:57-69. [PMID: 28131350 DOI: 10.1016/j.jen.2016.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/27/2016] [Accepted: 10/01/2016] [Indexed: 01/29/2023]
Abstract
The rise in ED utilization among older adults is a nursing concern, because emergency nurses are uniquely positioned to have a positive impact on the care of older adults. Symptoms have been associated with ED utilization; however, it remains unclear whether symptoms are the primary reason for ED utilization. The purpose of this study was to describe the self-reported symptoms of community-dwelling older adults prior to accessing the emergency department and to examine the differences in self-reported symptoms among those who did and did not utilize the emergency department. METHODS A prospective longitudinal design was used. The sample included 403 community-dwelling older adults aged 75 years and older. Baseline in-home interviews were conducted followed by monthly telephone interviews over 15 months. RESULTS Commonly reported symptoms at baseline included pain, feeling tired, and having shortness of breath. In univariate analysis, pain, shortness of breath, fair/poor well-being, and feeling tired were significantly correlated with ED utilization. In multivariable models, problems with balance and fair/poor well-being were significantly associated with ED utilization. DISCUSSION Several symptoms were common among this cohort of older adults. However, no significant differences were found in the types of symptoms reported by older adults who utilized the emergency department compared with those who did not utilize the emergency department. Based on these findings, it appears that symptoms among community-dwelling older adults may not be the primary reason for ED utilization.
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Green E, Ward S, Brierley W, Riley B, Sattar H, Harris T. "They Shouldn't Be Coming to the ED, Should They?": A Descriptive Service Evaluation of Why Patients With Palliative Care Needs Present to the Emergency Department. Am J Hosp Palliat Care 2017; 34:984-990. [PMID: 27903774 DOI: 10.1177/1049909116676774] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with palliative care needs frequently attend the emergency department (ED). There is no international agreement on which patients are best cared for in the ED, compared to the primary care setting or direct admission to the hospital. This article presents the quantitative phase of a mixed-methods service evaluation, exploring the reasons why patients with palliative care needs present to the ED. METHODS This is a single-center, observational study including all patients under the care of a specialist palliative care team who presented to the ED over a 10-week period. Demographic and clinical data were collected from electronic health records. RESULTS A total of 105 patients made 112 presentations to the ED. The 2 most common presenting complaints were shortness of breath (35%) and pain (28%). Eighty-three percent of presentations required care in the ED according to a priori defined criteria. They either underwent urgent investigation or received immediate interventions that could not be delivered in another setting, were referred by a health-care professional, or were admitted. CONCLUSIONS Findings challenge the misconception that patients known to a palliative care team should be cared for outside the ED. The importance and necessity of the ED for patients in their last years of life has been highlighted, specifically in terms of managing acute, unpredictable crises. Future service provision should not be based solely on a patient's presenting complaint. Further qualitative research exploring patient perspective is required in order to explore the decision-making process that leads patients with palliative care needs to the ED.
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Affiliation(s)
- Emilie Green
- 1 Royal Free Hospital, Royal Free London NHS Trust, London, United Kingdom
| | - Sarah Ward
- 2 Queen Mary University of London Medical School, Bart's Health NHS Trust, London, United Kingdom
| | - Will Brierley
- 2 Queen Mary University of London Medical School, Bart's Health NHS Trust, London, United Kingdom
| | - Ben Riley
- 2 Queen Mary University of London Medical School, Bart's Health NHS Trust, London, United Kingdom
| | - Henna Sattar
- 2 Queen Mary University of London Medical School, Bart's Health NHS Trust, London, United Kingdom
| | - Tim Harris
- 3 Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
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Ouchi K, Block SD, Schonberg MA, Jamieson ES, Aaronson EL, Pallin DJ, Tulsky JA, Schuur JD. Feasibility Testing of an Emergency Department Screening Tool To Identify Older Adults Appropriate for Palliative Care Consultation. J Palliat Med 2017; 20:69-73. [DOI: 10.1089/jpm.2016.0213] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | - Susan D. Block
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emily S. Jamieson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Yash Pal R, Kuan WS, Koh Y, Venugopal K, Ibrahim I. Death among elderly patients in the emergency department: a needs assessment for end-of-life care. Singapore Med J 2016; 58:129-133. [PMID: 27917433 DOI: 10.11622/smedj.2016179] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Elderly patients with serious chronic diseases often present to the emergency department (ED) in the last moments of their life, many with identifiable trajectories of dying: organ failure, advanced cancer and chronic frailty. These patients and their families may benefit more from good end-of-life (EOL) care provision than the standard resuscitative approach. This study aimed to determine the incidence and nature of death among patients aged ≥ 65 years in an ED, and characterise their trajectories of dying. METHODS This was a retrospective study carried out over a one-year period in a tertiary ED. All ED deaths in patients aged ≥ 65 years over this period were included. Information on the patients' demographics, comorbidities and details of death were extracted from the hospital's electronic medical records database. Based on the available information, their Karnofsky Performance Status (KPS) scores and trajectories of dying were ascertained. RESULTS In one year, 197 patients aged ≥ 65 years died in the ED, 51.3% of whom suffered from serious chronic illnesses, with identifiable trajectories of dying. Of these patients, 46.5% had premorbid functional limitation with KPS scores of 0-40. However, only 14.9% of patients had a pre-existing resuscitation status and 74.3% received aggressive resuscitative measures. CONCLUSION There is a significant burden of EOL care needs among elderly patients in the ED. Many of these patients have chronic illness trajectories of dying. This study underscores the need for improvement in EOL care provision for dying patients and their families in the ED.
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Affiliation(s)
- Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, Singapore
| | | | - Kuhan Venugopal
- Emergency Medicine Department, National University Hospital, Singapore
| | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, Singapore
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A Pilot Trial to Increase Hospice Enrollment in an Inner City, Academic Emergency Department. J Emerg Med 2016; 51:106-13. [DOI: 10.1016/j.jemermed.2016.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 02/04/2016] [Accepted: 03/26/2016] [Indexed: 11/18/2022]
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Kahn JH, Magauran BG, Olshaker JS, Shankar KN. Current Trends in Geriatric Emergency Medicine. Emerg Med Clin North Am 2016; 34:435-52. [DOI: 10.1016/j.emc.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Chikhladze N, Janberidze E, Velijanashvili M, Chkhartishvili N, Jintcharadze M, Verne J, Kordzaia D. Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey. BMC Palliat Care 2016; 15:63. [PMID: 27449224 PMCID: PMC4957836 DOI: 10.1186/s12904-016-0135-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings. METHODS The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant. RESULTS Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001). CONCLUSIONS The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.
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Affiliation(s)
- Nana Chikhladze
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Elene Janberidze
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Mariam Velijanashvili
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Nikoloz Chkhartishvili
- Georgian National Association for Palliative Care, Tbilisi, Georgia
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | | | - Dimitri Kordzaia
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
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Berendt J, Stiel S, Simon ST, Schmitz A, van Oorschot B, Stachura P, Ostgathe C. Integrating Palliative Care Into Comprehensive Cancer Centers: Consensus-Based Development of Best Practice Recommendations. Oncologist 2016; 21:1241-1249. [PMID: 27440065 DOI: 10.1634/theoncologist.2016-0063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/17/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND International associations admit that specialized palliative care (SPC) is an obvious component of excellent cancer care. Nevertheless, gaps in integration at the international level have been identified. Recommendations for integrating SPC in clinical care, research, and education are needed, which are subject of the present study. MATERIALS AND METHODS A Delphi study, with three written Delphi rounds, including a face-to-face-meeting with a multiprofessional expert panel (n = 52) working in SPC in 15 German Comprehensive Cancer Centers (CCCs) funded by the German Cancer Aid was initiated. Initial recommendations are built on evidence-based literature. Consensus was defined in advance with ≥80% agreement based on the question of whether each recommendation was unambiguously formulated, relevant, and realizable for a CCC. RESULTS A total of 38 experts (73.1%) from 15 CCCs performed all three Delphi rounds. Consensus was achieved for 29 of 30 recommendations. High agreement related to having an organizationally and spatially independent palliative care unit (≥6 beds), a mobile multiprofessional SPC team, and cooperation with community-based SPC. Until round 3, an ongoing discussion was registered on hospice volunteers, a chair of palliative care, education in SPC among staff in emergency departments, and integration of SPC in decision-making processes such as tumor boards or consultation hours. Integration of SPC in decision-making processes was not consented by a low-rated feasibility (76.3%) due to staff shortage. CONCLUSION Recommendations should be considered when developing standards for cancer center of excellence in Germany. Definition and implementation of indicators of integration of SPC in CCCs and evaluation of its effectiveness are current and future challenges. IMPLICATIONS FOR PRACTICE General and specialized palliative care (SPC) is an integral part of comprehensive cancer care. However, significant diversity concerning the design of SPC in the German Comprehensive Cancer Center (CCC) Network led to the establishment of consensual best practice recommendations for integration of SPC into the clinical structures, processes, research, and education throughout the CCC network. The recommendations contribute to a greater awareness relating to the strategic direction and development of SPC in CCCs. The access to information about SPC and access to offers regarding SPC shall be facilitated by implementing the recommendations in the course of treatment of patients with cancer.
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Affiliation(s)
- Julia Berendt
- Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Erlangen, Germany
| | - Stephanie Stiel
- Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Erlangen, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, University Hospital of Cologne and Centre for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Andrea Schmitz
- Interdisciplinary Center for Palliative Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Birgitt van Oorschot
- Interdisciplinary Center for Palliative Medicine, Comprehensive Cancer Center Mainfranken, University Hospital of Würzburg, Würzburg, Germany
| | - Peter Stachura
- Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Erlangen, Germany
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Ho A, Jameson K, Pavlish C. An exploratory study of interprofessional collaboration in end-of-life decision-making beyond palliative care settings. J Interprof Care 2016; 30:795-803. [DOI: 10.1080/13561820.2016.1203765] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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65
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da Silva Soares D, Nunes CM, Gomes B. Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review. J Palliat Med 2016; 19:601-9. [PMID: 27115914 PMCID: PMC4904160 DOI: 10.1089/jpm.2015.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evidence on best practice is scarce. OBJECTIVES To examine the effectiveness of ED-based PC interventions on hospital admissions (primary outcome), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults with advanced disease. METHODS We searched five databases until August 2014, checked reference lists/conference abstracts, and contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting outcomes of ED-based PC. RESULTS Five studies with 4374 participants were included: three case series and two cohort studies. Interventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital admissions: in one study there was no statistically significant difference in 90-day readmission rates between patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other outcomes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21-3.41); another study showed increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value). CONCLUSIONS There is yet no evidence that ED-based PC affects patient outcomes except for indication from one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these findings alongside other potential benefits and survival effects.
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Affiliation(s)
| | - Cristina Moura Nunes
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Bragança, Portugal
| | - Barbara Gomes
- Department of Palliative Care, Policy, and Rehabilitation, Cicely Saunders Institute, King's College, London, United Kingdom
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Green E, Shaw SE, Harris T. 'They shouldn't be coming to the ED, should they?' A qualitative study of why patients with palliative care needs present to the emergency department. BMJ Support Palliat Care 2016; 9:e29. [PMID: 27173972 DOI: 10.1136/bmjspcare-2015-000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 04/13/2016] [Accepted: 04/27/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Across the developed world, there are concerns about 'inappropriate' use of the emergency department (ED). Patients with palliative care needs frequently attend the ED. Previous studies define the 'reason' for presentation as the 'presenting symptom', which ignores the perspectives of service users. This paper addresses an acknowledged gap in the literature, which fails to examine the decision-making process that brings patients to the ED. METHODS In-depth narrative interviews were conducted with 7 patients (known to a specialist palliative care service and presenting to the ED during a 10-week period) and 2 informal caregivers. Analysis drew on 'Burden of Treatment Theory' to examine the meaning attributed by participants to their experience of serious acute illness, their capacity for action and the work required to access emergency care. RESULTS 5 themes were identified about how and why emergency services were accessed: capacity for action, making sense of local services, making decisions to access emergency services, experience of emergency care and coping with change. All narratives captured concerns surrounding the complexity of services. Participants struggled to piece together the jigsaw of services, and were subsequently more likely to attend the ED. Differences between the ways that patients with chronic obstructive pulmonary disease and cancer accessed the ED were prominent. CONCLUSIONS Further work is needed to understand and respond to decisions leading patients with palliative care needs to the ED, particularly in the context of locally fragmented services, poor signposting and confusion about available healthcare. The perspectives of service users are essential in shaping emergency care.
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Affiliation(s)
- Emilie Green
- Royal Free Hospital, Royal Free London NHS Trust, London, UK
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim Harris
- Royal London Hospital, Bart's Health Trust, London, UK
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67
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Kraus CK, Greenberg MR, Ray DE, Dy SM. Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors. J Pain Symptom Manage 2016; 51:898-906. [PMID: 26988848 DOI: 10.1016/j.jpainsymman.2015.12.334] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority. OBJECTIVES To assess PC competency education in EM residency programs. METHODS This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training. RESULTS Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues. CONCLUSION There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.
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Affiliation(s)
- Chadd K Kraus
- Department of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
| | - Marna R Greenberg
- Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Daniel E Ray
- Section of Palliative Medicine and Hospice, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sydney Morss Dy
- Duffey Pain/Palliative Care Program, Johns Hopkins Kimmel Cancer Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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68
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Tse JWK, Hung MSY, Pang SMC. Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study. J Emerg Nurs 2016; 42:224-32. [PMID: 27033338 DOI: 10.1016/j.jen.2015.10.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/11/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Provision of end-of-life (EOL) care in the emergency department has improved globally in recent years and has a different scope of interventions than traditional emergency medicine. In 2010, a regional hospital established the first ED EOL service in Hong Kong. METHODS The aim of this study was to understand emergency nurses' perceptions regarding the provision of EOL care in the emergency department. A qualitative approach was used with purposive sampling of 16 nurses who had experience in providing EOL care. Semi-structured, face-to-face interviews were conducted from May to October, 2014. All the interviews were transcribed verbatim for content analysis. RESULTS Four themes were identified: (1) doing good for the dying patients, (2) facilitating family engagement and involvement, (3) enhancing personal growth and professionalism, and (4) expressing ambiguity toward resource deployment. DISCUSSION Provision of EOL care in the emergency department can enhance patients' last moment of life, facilitate the grief and bereavement process of families, and enhance the professional development of staff in emergency department. It is substantiated that EOL service in the emergency department enriches EOL care in the health care system. Findings from this study integrated the perspectives on ED EOL services from emergency nurses. The integration of EOL service in other emergency departments locally and worldwide is encouraged.
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Affiliation(s)
| | - Maria Shuk Yu Hung
- Hong Kong Special Administrative Region of the People's Republic of China
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69
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Obermeyer Z, Clarke AC, Makar M, Schuur JD, Cutler DM. Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis. J Am Geriatr Soc 2016; 64:323-9. [PMID: 26805592 DOI: 10.1111/jgs.13948] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not. DESIGN Matched case-control study. SETTING Nationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011. PARTICIPANTS Beneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex. MEASUREMENTS Comparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls. RESULTS Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3-10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45-1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4-36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6-14.2%) of stays longer than 1 month. CONCLUSION Most Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.
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Affiliation(s)
- Ziad Obermeyer
- Department of Emergency Medicine, School of Medicine, Harvard University, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Ariadne Labs, Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts
| | - Alissa C Clarke
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maggie Makar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, School of Medicine, Harvard University, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts.,National Bureau of Economic Research, Cambridge, Massachusetts
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George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. J Pain Symptom Manage 2016; 51:108-19.e2. [PMID: 26335763 DOI: 10.1016/j.jpainsymman.2015.07.017] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 07/02/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects. OBJECTIVES To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED. METHODS Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. RESULTS Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral. CONCLUSION We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.
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Affiliation(s)
- Naomi George
- Brown University Alpert Medical School, Providence, Rhode Island, USA.
| | | | | | - Carolyn Song
- Mount Sinai School of Medicine, New York, New York, USA
| | | | - Corita Grudzen
- New York University Langone Medical Center, New York, New York, USA
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71
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Revels A, Goldberg L, Watson J. Caring Science: A Theoretical Framework for Palliative Care in the Emergency Department. ACTA ACUST UNITED AC 2016. [DOI: 10.20467/1091-5710-20.4.206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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72
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Waldrop DP, Clemency B, Lindstrom HA, Clemency Cordes C. "We Are Strangers Walking Into Their Life-Changing Event": How Prehospital Providers Manage Emergency Calls at the End of Life. J Pain Symptom Manage 2015; 50:328-34. [PMID: 25828561 DOI: 10.1016/j.jpainsymman.2015.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/21/2015] [Accepted: 03/12/2015] [Indexed: 11/20/2022]
Abstract
CONTEXT Emergency 911 calls are often made when the end stage of an advanced illness is accompanied by alarming symptoms and substantial anxiety for family caregivers, particularly when an approaching death is not anticipated. How prehospital providers (paramedics and emergency medical technicians) manage emergency calls near death influences how and where people will die, if their end-of-life choices are upheld and how appropriately health care resources are used. OBJECTIVES The purpose of this study was to explore and describe how prehospital providers assess and manage end-of-life emergency calls. METHODS In-depth and in-person interviews were conducted with 43 prehospital providers. Interviews were audiotaped, transcribed, and entered into ATLAS.ti for data management and coding. Qualitative data analysis involved systematic and axial coding to identify and describe emergent themes. RESULTS Four themes illustrate the nature and dynamics of emergency end-of-life calls: 1) multifocal assessment (e.g., of the patient, family, and environment), 2) family responses (e.g., emotional, behavioral), 3) conflicts (e.g., missing do-not-resuscitate order, patient-family conflicts), and 4) management of the dying process (e.g., family witnessed resuscitation or asking family to leave, decisions about hospital transport). After a rapid comprehensive multifocal assessment, family responses and the existence of conflicts mediate decision making about possible interventions. CONCLUSION The importance of managing symptom crises and stress responses that accompany the dying process is particularly germane to quality care at life's end. The results suggest the importance of increasing prehospital providers' abilities to uphold advance directives and patients' end-of-life wishes while managing family emotions near death.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York, USA.
| | - Brian Clemency
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, New York, USA; Department of Emergency Medicine, Erie County Medical Center, Buffalo, New York, USA
| | - Heather A Lindstrom
- Department of Emergency Medicine, Erie County Medical Center, Buffalo, New York, USA
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73
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Consultations en soins de support oncologiques mono-, multi-, ou interdisciplinaires : que privilégier ? Bull Cancer 2015; 102:786-91. [DOI: 10.1016/j.bulcan.2015.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/18/2015] [Accepted: 04/18/2015] [Indexed: 11/30/2022]
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Abstract
Patients seek care in the emergency department (ED) for immediate relief of pain or other symptoms. Emergency physicians are trained to provide care that focuses on disease-directed treatment of acute illnesses; the ED is not considered an entry point for palliative care. Despite this, many patients with chronic or end-stage diseases seek treatment in the ED each year. Improving quality of life (QOL) is an overarching principle of palliative care. The ED is poised to improve patients' QOL by providing palliative interventions to manage pain and exacerbations of chronic illnesses or care near the end of life.
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Affiliation(s)
- Laurence M Solberg
- Division of Geriatric Medicine, Department of Aging and Geriatric Research, University of Florida College of Medicine, 2004 Mowry Road, Mailbox 112610, Gainesville, FL 32610, USA.
| | - Jacobo Hincapie-Echeverri
- Division of Geriatric Medicine, Department of Aging and Geriatric Research, University of Florida College of Medicine, 2004 Mowry Road, Mailbox 112610, Gainesville, FL 32610, USA
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75
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Weil J, Weiland TJ, Lane H, Jelinek GA, Boughey M, Marck CH, Philip J. What's in a name? A qualitative exploration of what is understood by "palliative care" in the emergency department. Palliat Med 2015; 29:293-301. [PMID: 25634627 DOI: 10.1177/0269216314560801] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The understanding of what palliative care is, and which patients may benefit from palliative care, has important implications for optimal patient care in all areas of health provision. AIM To explore the understanding of palliative care by healthcare professionals caring for patients with advanced cancer attending emergency departments. DESIGN Qualitative study, with two phases: the first, a series of focus groups with healthcare professionals from various disciplines and settings caring for patients with advanced cancer presenting to emergency departments; the second, semi-structured telephone interviews with emergency healthcare professionals across Australian States and Territories, including outside metropolitan centers. The data were audio-recorded and transcribed, with analysis undertaken using a qualitative thematic analysis. SETTING/PARTICIPANTS Saturation of themes was reached after 8 focus groups (22 emergency nurses, 21 emergency physicians, 6 oncologists, 6 hospital palliative care clinicians, and 28 community palliative care clinicians) and 11 telephone interviews (8 emergency physicians and 3 emergency nurses), a total of 94 participants. RESULTS The overarching theme was that healthcare professionals held contradictory understandings of palliative care and its application in the emergency department; subthemes highlighted these inconsistencies when the term "palliative" is used, in understandings of and engagement with palliative care services and in perceptions about the practical utility of palliative care. CONCLUSION There are entrenched contradictions and tensions surrounding the term "palliative care"; confronting these is likely to require more than re-branding, and will promote better care for this vulnerable patient group in the emergency department.
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Affiliation(s)
- Jennifer Weil
- Centre for Palliative Care, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Tracey J Weiland
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Heather Lane
- Centre for Palliative Care, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - George A Jelinek
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark Boughey
- Centre for Palliative Care, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Claudia H Marck
- Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Jennifer Philip
- Centre for Palliative Care, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
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Abstract
The emergency department cares for seriously ill patients across the trajectory of illness from diagnosis to death or cure. Emergency departments participate in critical illness trajectories that include initiation of life-sustaining therapies as well as caring for patients and families in their final moments of life. Emergency clinicians are uniquely poised to identify critical palliative care interventions to be used when patients and families are most in need with respect to symptom management, decisions regarding intervention and procedures to sustain life and participate in critically important decisions regarding withdrawing and withholding nonbeneficial life-sustaining therapies.
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Affiliation(s)
- Derrick S Lowery
- Emory University School of Medicine, 1462 Clifton Road, Suite 302, Atlanta, GA 30322, USA
| | - Tammie E Quest
- Department of Emergency Medicine, Emory Palliative Care Center, Emory School of Medicine, 1462 Clifton Road, Suite 302, Atlanta, GA 30322, USA.
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77
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Gray LM, Meyer S. Management of patients on chemotherapeutic treatment for advanced cancer with acute conditions in the emergency department. ACTA ACUST UNITED AC 2014; 17:146-51. [DOI: 10.1016/j.aenj.2014.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 11/16/2022]
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78
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Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med 2014; 14:633-6. [PMID: 24381685 PMCID: PMC3876308 DOI: 10.5811/westjem.2013.5.14674] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 05/05/2013] [Accepted: 05/06/2013] [Indexed: 02/06/2023] Open
Abstract
An integrated model of palliative care in the emergency department (ED) of an inner city academic teaching center utilized existing hospital resources to reduce hospital length of stay (LOS) and reduce overall cost. Benefits related to resuscitation rates, intensity of care, and patient satisfaction are attributed to the ED-based palliative team’s ability to provide real time consults, and utilize InterQual criteria to admit to a less costly level of care or transfer directly to home or hospice.
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Affiliation(s)
- Mark Rosenberg
- Department of Emergency Medicine, St. Joseph's Health Care System, Paterson, New Jersey
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79
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Waldrop DP, Clemency B, Maguin E, Lindstrom H. Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians. J Palliat Med 2014; 17:338-41. [PMID: 24517266 DOI: 10.1089/jpm.2013.0442] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department. OBJECTIVE To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls. DESIGN This descriptive study used a cross-sectional survey design with mixed methods. SETTING/PARTICIPANTS One hundred seventy-eight prehospital providers (76 EMT-basics and 102 paramedics) from an emergency medical services agency participated. MEASUREMENTS Multiple choice and open-ended survey questions addressed how they learned about EOL calls, their confidence with advance directives, and perspectives on improving care in the field. RESULTS The response rate was 86%. Education about do-not-resuscitate (DNR) orders was formal (92%), experiential (77%), and self-directed (38%). Education about medical orders for life-sustaining treatment (MOLST) was formal (72%), experiential (67%), and self-directed (25%). Ninety-three percent were confident in upholding a DNR order, 87% were confident interpreting MOLST, and 87% were confident sorting out conflict between differing patient and family wishes. Qualitative data analysis yielded six themes on improving preparation of prehospital providers for EOL calls: (1) prehospital provider education; (2) public education; (3) educating health care providers on scope of practice; (4) conflict resolution skills; (5) handling emotional families; and (6) clarification of transfer protocols. CONCLUSION These study results suggest the need for addressing the potential interrelationship between prehospital and EOL care through improved education and protocols for care in the field.
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80
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Woolley DC, Old JL, Zackula RE, Davis N. Acute Hospital Admissions of Hospice Patients. J Palliat Med 2013; 16:1515-22. [DOI: 10.1089/jpm.2013.0033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Jerry L. Old
- Kansas University School of Medicine, Wichita, Kansas
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81
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Wu FM, Newman JM, Lasher A, Brody AA. Effects of Initiating Palliative Care Consultation in the Emergency Department on Inpatient Length of Stay. J Palliat Med 2013; 16:1362-7. [DOI: 10.1089/jpm.2012.0352] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Frances M. Wu
- Sutter Health Research, Development, and Dissemination, Concord, California
| | - Jeffrey M. Newman
- Sutter Health Research, Development, and Dissemination, Concord, California
| | - Andrew Lasher
- California Pacific Medical Center, San Francisco, California
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82
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Bradley V, Burney C, Hughes G. Do patients die well in your emergency department? Emerg Med Australas 2013; 25:334-9. [PMID: 23911024 DOI: 10.1111/1742-6723.12099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Although the role of the ED in the management of patients needing palliative care is recognised internationally, there are little Australasian data on this issue. This study aimed to determine the current knowledge and attitude to the provision of palliative care in Australasian EDs. METHODS All ED directors in Australasia were invited to complete an online survey about the provision of palliative care in their department. Quantitative data were described using counts and proportions, and qualitative data were summarised thematically. RESULTS Of 165 eligible ED directors, 35 completed the survey (22%; 95% CI, 15-28%). Only 17/35 (49%; 95% CI, 32-65%) believed that ED provided good palliative care, and 28/35 (80%; 95% CI, 67-93%) were unaware of international gold standard palliative care protocols. Most had access to hospital-based palliative care specialists 27/35 (77%; 95% CI, 63-91%); however, only 5/27 (19%; 95% CI, 4-33%) used them. Few EDs undertake formal training in palliative care 10/35 (29%; 95% CI, 16-45%). Respondents showed concern about the quality of palliative care they provide and advocated for more palliative care training. CONCLUSION Although limited by the low response rate, this survey indicates that there is a need and a desire for greater integration of the values and standards of high-quality palliative care in Australasian EDs.
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Affiliation(s)
- Victoria Bradley
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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83
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McNamara BA, Rosenwax LK, Murray K, Currow DC. Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death. J Palliat Med 2013; 16:774-9. [PMID: 23676094 DOI: 10.1089/jpm.2012.0403] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Overcrowded emergency departments (EDs) and the staff within them are often not able to address the complex physical and psychosocial needs of people at the end of life. While some studies have suggested that the ED environment should be adapted and staff trained to address this issue, there are no previous studies which have investigated whether the provision of timely palliative care services could prevent people with palliative care needs from attending EDs. OBJECTIVE This study investigates whether early admission to community-based palliative care reduces ED admissions in the last 90 days of life for patients with cancer. METHODS The study was a retrospective, cross-sectional study using death registrations and hospital morbidity data for 746 Western Australian adults who died of cancer and where palliative care may have been a viable and appropriate option for care. RESULTS In their final 90 days before death, 31.3% of decedents who had early access to palliative care and 52.0% of those who did not have early access to palliative care visited an ED (OR=2.86; 95% CI, 1.91, 4.30). Early admission to community-based palliative care reduces the use of EDs by cancer patients in the 90 days before death. CONCLUSIONS Proactive care in the form of timely community-based palliative care assists in preventing vulnerable people at the end of life from being exposed to the stressful ED environment and decreases the pressure on EDs.
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Affiliation(s)
- Beverley A McNamara
- Centre for Research into Disability and Society and Curtin Health Innovation Research Institute, School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
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84
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Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013. [PMID: 23177598 DOI: 10.1016/j.cger.2012.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.
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85
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Jelinek GA, Marck CH, Weiland TJ, Philip J, Boughey M, Weil J, Lane H. Caught in the middle: Tensions around the emergency department care of people with advanced cancer. Emerg Med Australas 2013; 25:154-60. [DOI: 10.1111/1742-6723.12047] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Claudia H Marck
- Emergency Practice Innovation Centre; St Vincent's Hospital; Melbourne; Victoria; Australia
| | | | | | | | - Jennifer Weil
- Palliative Medicine; St Vincent's Hospital; Melbourne; Victoria; Australia
| | - Heather Lane
- Palliative Medicine; St Vincent's Hospital; Melbourne; Victoria; Australia
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86
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Tahmasebi M. Palliative Care for the End-of-Life Cancer Patients in the Emergency Department in Iran. IRANIAN JOURNAL OF CANCER PREVENTION 2013; 6:231-2. [PMID: 25250140 PMCID: PMC4142933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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87
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:402-16. [DOI: 10.1097/spc.0b013e3283573126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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88
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Fullerton SL, Kenner DJ, Tucker MT. “Anywhere to palliative care” — a fast‐track pathway from the emergency department to palliative care. Med J Aust 2012; 196:566. [DOI: 10.5694/mja12.10521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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89
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Lawson R. Palliative social work in the emergency department. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2012; 8:120-134. [PMID: 22680048 DOI: 10.1080/15524256.2012.685427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Recognizing that seriously ill patients and their families utilize emergency departments (EDs) for distressing symptoms, changing goals of care, or at the end of life, palliative care and emergency medicine departments are partnering to enhance the care provided to patients with life-limiting illnesses and their families. A social work model for identifying patients with unmet palliative care needs in the ED is included to illustrate the process as well as specific psychosocial interventions that palliative social workers can provide in this environment. As increasing numbers of palliative and emergency medicine departments partner to both improve ED care for patients with life-threatening illness and initiate palliative care consults earlier in hospitalizations, palliative and ED social workers have an opportunity to join their physician and nurse colleagues who are making inroads in this important and growing area.
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