[Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care]

[End-of-life care in the emergency department-Indications for admission and spectrum of care-State of the art]

BACKGROUND

Emergency departments (EDs) and ED observation units provide care for a wide range of medical emergencies, serving patients of all ages and conditions. This includes palliative care for patients who are rapidly deteriorating. However, there is limited knowledge about the incidence, reasons for ED visits, modes of arrival, symptoms, leading diagnoses, and the emergency care provided to these patients until the time of death.

METHOD

This retrospective, exploratory study was conducted at the 754-bed Kliniken Maria Hilf academic teaching hospital in Moenchengladbach, Germany. It included patients who died in the ED resuscitation rooms or ED observation unit between 1st of July 2018 and 30th of June 2023. We utilized routine data to analyze the reasons for ED visits, modes of arrival, symptoms, diagnoses and the medical care provided. We also examined differences between oncologic and non-oncologic patients as well as between those requiring cardiopulmonary resuscitation (CPR) and those who did not. The study was approved by an ethics committee and categorical data were analyzed using the χ2-test with Yates correction. P-values < 0.05 were considered significant due to the exploratory nature of the study.

RESULTS

During the study period 168,328 patients were treated in the ED, with 43% admitted to the hospital. Of these, 262 died in the ED or ED observation unit. The primary mode of arrival was emergency medical services for 234 patients (89%). The most common symptoms were impaired consciousness (n = 198; 76%) and dyspnea (n = 83; 32%), among a range of others. Comparing non-oncologic (n = 214) and oncologic patients (n = 48), the former showed significantly higher rates of impaired consciousness (174/214 vs. 24/48; p = 0.0001), while dyspnea was more prevalent in oncologic patients (57/214 vs. 26/48; p = 0.0002). Among patients who underwent CPR (n = 147) and those who did not (n = 115), no statistical differences were found in levels of consciousness but a significant difference in dyspnea (prior to cardiac arrest) was noted (31/147 vs. 52/115; p = 0.0001). Palliative status was documented in 88 cases (34%), with palliative care initiated in only 58 (21%). Only three patients (1%) were receiving specialized outpatient palliative care (SAPV). The most common medical interventions were invasive ventilation (n = 160; 61%), opioid administration (n = 145; 55%), CPR (n = 143; 55%), and crystalloid administration (n = 90; 34%). Structured communication with relatives occurred in 188 cases (72%).

CONCLUSION

The incidence of death in a large German ED was approximately one patient per week. These patients typically presented with symptoms common in critically ill non-trauma cases. The low incidence of SAPV patients (1%) suggests its potential to reduce ED admissions. Oncologic patients were a minority, possibly due to effective outpatient care and lower mortality within the first 24 h after ED admission. Emergency palliative care in the ED could alleviate the burden on intensive care units. Training ED staff in acute palliative care and establishing procedural standards for such care are essential to maintain high-quality treatment, given the frequency of palliative cases in the ED.

[Survey on the presence of palliative care knowledge and palliative care structures in German emergency departments]

Patients with life-limiting or palliative illnesses represent a challenge for emergency departments because, despite the growing availability of specialized outpatient palliative care resources at home, patients often present during symptom exacerbations or when family caregivers become overwhelmed. Also, as life-limiting illnesses are frequently first diagnosed there and treatment goals are adjusted, it appears advantageous to establish early connections between emergency patients with palliative needs and palliative care resources. The objective of this study was to conduct a survey evaluating the availability of fundamental palliative care knowledge and palliative care structures in clinical acute and emergency medicine. For this purpose, an online survey was distributed via emergency medicine blogs, targeting physicians working in emergency departments. In total, 383 fully completed questionnaires were analyzed. It was found that the respondents often encounter patients with palliative needs. However, both outpatient and inpatient palliative resources are not universally accessible, and where, for instance, consultation services are available, there is a lack of consensus regarding the appropriate timing for their utilization. Structures for end of life care are largely in place, although time and personnel are often insufficiently available. There is an expressed interest in further education and training in palliative care. In conclusion, as emergency departments serve as the interface between outpatient and inpatient care, an interdisciplinary and holistic approach can be employed to lay the groundwork for ongoing palliative care, benefiting patients with palliative needs.

[PARPACT: Paramedic Palliative Care Test : Validation of a questionnaire to assess palliative care knowledge and self-efficacy expectations of paramedics]

Hintergrund

Angesichts der Vielzahl von Palliativpatienten, die vom Rettungsdienst versorgt werden, spielen Aus- und Weiterbildung in palliativmedizinischen Themen eine immer größere Rolle. Zur Verbesserung der Entscheidungsfindung in Rettungssituationen wurde in vielen Städten ein Palliativ- bzw. Notfallausweis eingeführt.

Ziel der Arbeit

Um den Erfolg von Bildungsmaßnahmen und den Effekt des Palliativ- bzw. Notfallausweises zu überprüfen, wurde ein Fragebogen zur Ermittlung von palliativem Wissen und palliativer Selbstwirksamkeitserwartung im Rettungsdienst entwickelt und validiert.

Material und Methoden

Die Entwicklung und Inhaltsvalidierung erfolgte mithilfe eines Delphi-Prozesses. Zur Konstruktvalidierung wurde die Faktorenanalyse genutzt. Die Kriteriumsvalidität wurde anhand von 22 speziell in Palliative Care geschulten Pflegekräften überprüft. Die Reliabilität wurde mittels Cronbachs α als Maß der internen Konsistenz ermittelt.

Ergebnisse

291 von 750 Rettungsdienstmitarbeitern nahmen an der freiwilligen Befragung teil. Nach Abschluss des Delphi-Prozesses bestand Konsens, dass die wichtigen Themen Schmerz, Dyspnoe, Sedierung, Sterbebegleitung, Sterbehilfe und rechtliche Aspekte im Fragebogen abgedeckt sind. Das Ergebnis der Faktorenanalyse sprach für eine 6‑Faktoren-Lösung. Bei der Kriteriumsvalidierung zeigte sich ein signifikanter Unterschied im palliativen Wissen zwischen den Palliative-Care-Pflegekräften (M_Rang 289,73) und den Rettungsdienstmitarbeitern (M_Rang 146,97, U = 281.000, r = 0,40, p < 0,001). Cronbachs α lag für die Wissensfragen bei 0,70 und für die Subskala der palliativen Selbstwirksamkeitserwartung bei 0,82.

Diskussion

Mit dem Paramedic Palliative Care Test (PARPACT) liegt ein validiertes Messinstrument zur Überprüfung von Bildungsmaßnahmen im Rettungsdienst vor.

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases

Introduction

The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment.

Methods

Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis.

Results

We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver's emotions, coping and understanding of patient's illness, patient's wishes, coping and understanding of patient's illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians' knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested.

Conclusion

Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

Healthcare Received in the Last Months of Life in Portugal: A Systematic Review

Background: While evidence demonstrates that end-of-life care practices vary across countries, there is still a lack of evidence regarding the healthcare that is received by adult individuals in the last months of life in Portugal. Methods: This is a systematic review that aims to examine the evidence published until 2019 regarding the healthcare received by adult individuals in the last months of life in Portugal. Results: Nine studies were included in this review. All of these were quantitative and retrospective studies, used patient records as the source of information, and were conducted in hospital settings. The time frame analysis before death ranged from 48 h to 3 months. The majority of the studies focused on the physical aspects of care, such as physical needs assessment and symptom management, prescribed medication, and invasive interventions. No evidence was found regarding spiritual, psychological, social or cultural needs. Conclusion: Although using patient records as a source of information may introduce a bias, this study indicates that there is a greater emphasis on the physical aspects of care and less on the psychological, spiritual or social aspects of care received by adult individuals in their last months of life in Portugal.

[Outpatient palliative medicine : Attitudes in the care of palliative emergencies. Prospective questionnaire-based investigation]

BACKGROUND

The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations.

METHODS

A standardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions.

RESULTS

The survey response rate was 79% from a total of 81 SPCS in 2011. The following standards in palliative emergency care were recommended: (1) early integration of outpatient palliative care services and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4) emergency medical training (physicians and paramedics).

CONCLUSION

Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.

[Medicolegal aspects in emergency medical care : Analysis of the frequency of advance health care directives and the influence on decision making in emergency medicine]

BACKGROUND

Medical decisions in an emergency medical services (EMS) situation are always extremely time- critical and sensitive, potentially leading to medicolegal consequences. Advance health care directives (AHCDs) are crucial components in the patients' participative decision making. When a patient refuses resuscitation, and/or other life-extending treatments, emergency physicians face possible ethical, medical, and medicolegal conflicts.

METHODS

As part of the RIMANO II Study [Risk Management Präklinische (prehospital) Notfallmedizin (emergency medicine)], all 18 "emergency physician bases" of the Berlin Fire Department were polled regarding the influence of AHCDs in regard to emergency medical decision making. The assessment was based on anonymous questionnaires. Furthermore, emergency medical suggestions for improvement of AHCDs were gathered. Descriptive statistics and qualitative methods were used for evaluation.

RESULTS

A total of 112 responses from emergency physicians could be incorporated into the study. Anesthesiologists represented the largest group (n = 55, 49 %), followed by internists (n = 40, 36 %). The median length of experience in EMS was 7 years [interquartile range (IQR) 4-14 years]. Patients' "do not resuscitate" orders were obeyed in 78/112 cases (70 %, 95 % CI 69-78 %). In 49/112 cases (44 %, 95 % CI 34-53 %), the request to not be hospitalized was granted. The length of EMS experience, type of medical specialty, the number of EMS cases and ways in which AHCDs were handled were all contributing factors to the various emergency medical interventions.

CONCLUSION

AHCDs appear to have an influence in the emergency medical decision process. However, it is presently unclear as to what a standardized and universally comprehensible AHCD should look like, in order to provide a framework that is both acceptable and necessary in a prehospital emergency medicine environment, ensuring medicolegal certainty for the parties involved.

[Ethics in intensive care and euthanasia : With respect to inactivating defibrillators at the end of life in terminally ill patients]

BACKGROUND

In critically ill patients, intensive care medical procedures allow diseases to be cured or controlled that were considered incurable many years ago. For patients with terminal heart failure or heart disease with other severe comorbidities (cancer, stroke), the questions whether the deactivation of defibrillators is appropriate or must be regarded as active euthanasia may arise.

MATERIALS AND METHODS

Notable cases from the author's hospital are analyzed. The literature on the topic euthanasia and basic literature regarding defibrillator therapy are discussed.

DISCUSSION AND CONCLUSION

It is undisputed that patients as part of their self-determination have the right to renounce treatment. Active euthanasia and the thereby deliberate induction of death is prohibited by law in Germany and will be prosecuted. Passive euthanasia is the omission or reduction of possibly life-prolonging treatment measures. Passive euthanasia requires the patient's consent and is legally and ethically permissible. Indirect euthanasia takes into account acceleration of death as a side effect of a medication. Unpunishable assisted suicide ("assisted suicide") is the mere assistance of self-controlled and self-determined death. Assisted suicide is fundamentally not a criminal offense in Germany. Deactivation of a defibrillator is a treatment discontinuation, which is only permitted in accordance with the wishes of the patient. It is not a question of passive or active euthanasia. Involvement of a local ethics committee and/or legal consultation is certainly useful and sometimes also allows previously unrecognized questions to be answered.

[Patients' declared intentions and emergency medicine]

Patients with complex medical problems and acute life-threatening diseases deserve a physician with the capability of rapid decision making. Despite an emergency scenario with several unknown or uncertain variables an individual therapeutic plan needs to be defined for each patient. In order to achieve this goal the physician must define medical indications for each form of treatment. Secondly, the patients declared intentions must be respected concerning the previously defined medical indications; however, very often the patients' will is not known. It is very difficult to define an individual treatment plan especially if the patient is not able to adequately communicate. In these situations a custodian is helpful to find out the patients declared intentions towards the current medical situation. If there is no advance directive, family members often have to act as surrogates to find out what therapy goal is best for the individual patient. The patients' autonomy is a very highly respected ethical priority even when the ability for the otherwise usual practice of shared decision-making between physician and patient is compromised. Therefore, in order to do justice to this demanding situation it is necessary to deal with the characteristics of the physician-patient-relatives relationship in emergency medicine.

[The palliative patient as an emergency patient: A model for decision making in life-threatening situations using 4 case reports]

BACKGROUND

Increasingly more patients reaching our hospitals as an emergency are chronically ill or are in advanced stages of infaust, e.g., malignant, diseases. On the other hand, the treatment options for malignant diseases are improving. In an emergency, a decision must be made between life-sustaining treatment (in the context of a potentially poor prognosis) versus palliation.

DEVELOPMENT OF A DECISION-MAKING MODEL

The current literature about this topic is heterogeneous. The aim of the present article is to present a method using four case reports to decide either for life-sustaining treatment or for palliation with the help of the following: (1) the prognosis of the chronic disease and (2) the association of the acute situation with the chronic disease.

CONCLUSION

This method has an advisory role and cannot be taken as a guideline. Its usefulness can only be proven in practice.

[Advance directives in prehospital emergency treatment : prospective questionnaire-based analysis]

BACKGROUND

The handling of advance directives (AD) in prehospital emergency treatment in Germany is characterized by instability. In the project "Advance directives in preclinical emergency medical aid" ("Patientenverfügungen in der präklinischen Notfallmedizin") the frequency and quality of ADs in emergency situations was investigated.

AIM

The aim of this study was to fill the gaps in research and to collate data on how consideration of the self-determination of patients in emergency situations can be optimized.

MATERIAL AND METHODS

Over a period of 12 months from December 2007 to December 2008 a questionnaire was included in the emergency documentation of the medical emergency service in Aachen. Emergency patients were asked by emergency physicians to provide an AD and the quantitative as well as qualitative features of these ADs were examined. Furthermore, the study recorded what kinds of problems occurred with ADs in emergency situations and what measures were needed to correct this deficiency. The reactions of patients were documented on a numeral rating scale with a score of 1 reflecting a negative and 10 reflecting a positive reaction. In the 12-month period emergency doctors recorded 1,321 missions and after application of the exclusion criteria (e.g. missing signature, incomplete documentation and late delivery) 1,047 documented questionnaires were available for the analysis.

RESULTS

A total of 127 out of 1,047 emergency patients provided an AD, 44 had a durable power of attorney and 27 had appointed a legal representative for healthcare. Of the emergency patients 20 had a legal attendant and 43 out of the 127 ADs could be presented to the emergency team during the emergency mission. The emergency team often encountered difficulties regarding the handling of the ADs due to the time factor and unclear wording. The latter included the following problems: misleading formulation (19.1 %), difficulty with the complexity (14.9 %) and contradicting information (4 %). Only 29 (61.7 %) of the durable powers of attorney were signed and legally binding. From the view of the emergency physicians the following information was lacking but would be helpful in emergency situations: emergency plan, hierarchy of those given power of attorney, knowledge of risks regarding ADs and medication requirements.

CONCLUSION

The results show that for an AD to apply in an emergency situation certain standards are necessary that assure the practicability, especially if a patient does not wish to be resuscitated. Most difficulties with ADs occurred with imprecise formulation, text length and inconsistency of statements. The following instructions were usually missing: hierarchy of those given power of attorney and specification on medication, information about the scope of the ADs, statement about resuscitation, extent and limitations of the desired treatment, especially with patients certified as terminally ill and instructions on who should decide about medical treatment in a conflict situation. A so-called emergency instruction which gives on a single page the patient's statement on resuscitation would have been very helpful in individual cases. The results suggest that patients may need more information and education about AD to guarantee patients rights and self-determination.

International recommendations for outpatient palliative care and prehospital palliative emergencies - a prospective questionnaire-based investigation

Background

To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts.

Methods

One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical .

Results

The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics).

Conclusions

This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

[Palliative care oriented therapy for all patients : recommendations of an expert circle]

BACKGROUND

Since 2011 palliative care has been a compulsory part of the German medical study course (so-called Q13 palliative and pain medicine). Palliative care content does not, however, as often taught, have to focus only on patients in the so-called palliative stages of disease. The aim of this investigation was to encourage a discussion concerning the integration of palliative care aspects into general medical treatment.

METHODS

For data collection an open discussion of the main topics by experts in palliative medical care was used. The main outcome measures and recommendations included responses regarding current practices related to expert opinions, national and international literature and one case report. The literature search was performed using the databases "PubMed", "Medline" and "Google" (1990-2011).

RESULTS

As an important consensus, the following recommendations for optimization of inpatient and outpatient care were: (1) integration of aspects of palliative care into medical curricula of all disciplines, (2) palliative care content should be extended to the general optimization of therapy for all patients, (3) palliative medicine should be part of the everyday medical practice in all disciplines and (4) palliative medicine should not be isolated as "death medicine" or medicine of the dying patient.

CONCLUSIONS

Palliative care treatment is increasingly becoming integrated into medical education and into medical curricula of all disciplines. Palliative ideas and goals are focussed on patients in the so-called palliative stages of disease. Furthermore, palliative medicine is often described as the medicine of dying patients. As a result of this study it seems to make sense to extend palliative care aspects to all patients and to all patient care. The extent to which such opportunities exist and such health care is economically feasible remains to be the subject of further clinical studies.

A Literature Review on Care at the End-of-Life in the Emergency Department

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.