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Shams-Vahdati N, Shams Vahdati S, Samad-Soltani T. Design and evaluation of collaborative decision-making application for patient care in the emergency department. Health Sci Rep 2024; 7:e1931. [PMID: 38410500 PMCID: PMC10895157 DOI: 10.1002/hsr2.1931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/05/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
Background and Aims Collaboration has become a crucial element of effective healthcare delivery in the emergency department (ED). In high-pressure environments, healthcare providers can prioritize patients by consulting with other specialists to gain diverse perspectives and arrive at a shared understanding of the best course of action. It was conducted for the purpose of designing and evaluating the collaborative decision-making application for patient care in the ED. Methods The present applied research study was conducted between April 1, 2021 and May 31, 2023 at Imam Reza Hospital of Tabriz University of Medical Sciences. The study was conducted in three phases: exploration, development, and evaluation, utilizing modern technologies such as Flutter and Node.js to design and program the application. The effectiveness of the system was evaluated using established measures, including the think-aloud protocol, user experience questionnaire, and Likert-scale questionnaires developed by Ghadri et al. Results The average scale for attractiveness was 2.03, perspicuity was 2.90, efficiency was 2.40, dependability was 1.93, stimulation was 2.48, and novelty was 2.78. Additionally, 71% of physicians gave a very good rating to the accessibility of necessary information at any time, motivation to use the system for accessing information, usefulness of the system compared to the time spent using it throughout the day. Furthermore, 57% of physicians gave a very positive rating to sharing information and knowledge, ease of using the search function and accessing the system, user control and monitoring, free access to the system, and support from colleagues and system users. Conclusion The study suggests that introducing Information and Communication Technology such as medical apps can improve healthcare delivery by streamlining patient care, promoting effective teamwork, and reducing medical errors and treatment delays.
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Affiliation(s)
- Neda Shams-Vahdati
- Department of Health Information Technology, School of Management and Medical Informatics Tabriz University of Medical Sciences Tabriz Iran
| | - Samad Shams Vahdati
- Emergency and Trauma Care Research Center Tabriz University of Medical Sciences Tabriz Iran
| | - Taha Samad-Soltani
- Department of Health Information Technology, School of Management and Medical Informatics Tabriz University of Medical Sciences Tabriz Iran
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Disclosure of Medical Errors. Ann Emerg Med 2023; 82:e81-e85. [PMID: 37479417 DOI: 10.1016/j.annemergmed.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 07/23/2023]
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Benesch TD, Moore JE, Breyre AM, DeWitt R, Nattinger CC, Dellinger E, Anderson ES, Bulman L. Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention. AEM EDUCATION AND TRAINING 2022; 6:e10823. [PMID: 36562021 PMCID: PMC9763971 DOI: 10.1002/aet2.10823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 05/31/2023]
Abstract
Background Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Methods Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM. Results The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use. Conclusions An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.
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Affiliation(s)
| | | | - Amelia M. Breyre
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Raizel DeWitt
- Joint Medical ProgramUniversity of California, Berkeley and University of California, San FranciscoCaliforniaBerkeleyUSA
| | - Caroline C. Nattinger
- Joint Medical ProgramUniversity of California, Berkeley and University of California, San FranciscoCaliforniaBerkeleyUSA
| | | | | | - Linda Bulman
- Alameda Health SystemHighland HospitalOaklandCaliforniaUSA
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Chang JCY, Yang C, Lai LL, Huang HH, Tsai SH, Hsu TF, Yen DHT. Differences in Characteristics, Hospital Care, and Outcomes between Acute Critically Ill Emergency Department Patients Receiving Palliative Care and Usual Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312546. [PMID: 34886271 PMCID: PMC8656613 DOI: 10.3390/ijerph182312546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.
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Affiliation(s)
- Julia Chia-Yu Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (C.Y.); (L.-L.L.)
| | - Li-Ling Lai
- Department of Nursing, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (C.Y.); (L.-L.L.)
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Teh-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (J.C.-Y.C.); (H.-H.H.); (T.-F.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Emergency Medicine, National Defense Medical Center, Taipei 11490, Taiwan;
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 30015, Taiwan
- Correspondence:
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Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med 2021; 78:658-669. [PMID: 34353647 DOI: 10.1016/j.annemergmed.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.
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Affiliation(s)
- Anthony J Loffredo
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA
| | - David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, CA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Eric D Isaacs
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Rachel Pearl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Rosenberg
- Department of Emergency Medicine, St Joseph's Health, Paterson and Wayne, NJ
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St Joseph's Health, Paterson, NJ; Department of Emergency Medicine, Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
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Hughes K, Achauer S, Baker EF, Knowles HC, Clayborne EP, Goett RR, Moussa M. Addressing end-of-life care in the chronically ill: Conversations in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12569. [PMID: 34632450 PMCID: PMC8486416 DOI: 10.1002/emp2.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.
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Affiliation(s)
- Katarina Hughes
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Samantha Achauer
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | | | | | - Elizabeth P. Clayborne
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | - Mohamad Moussa
- Emergency MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOhioUSA
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Russell E, Hall AK, McKaigney C, Goldie C, Harle I, Sivilotti MLA. Code Status Documentation Availability and Accuracy Among Emergency Patients with End-stage Disease. West J Emerg Med 2021; 22:628-635. [PMID: 34125038 PMCID: PMC8203022 DOI: 10.5811/westjem.2020.12.46801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/24/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Some patients with end-stage disease who may neither want nor benefit from aggressive resuscitation receive such treatment if they cannot communicate in an emergency. Timely access to patients' current resuscitation wishes, or "code status," should be a key metric of electronic health records (EHR). We sought to determine what percentage of a cohort of patients with end-stage disease who present to the emergency department (ED) have accessible, code status documents, and for those who do, how quickly can this documentation be retrieved. METHODS In this cross-sectional study of ED patients with end-stage disease (eg, palliative care, metastatic malignancy, home oxygen, dialysis) conducted during purposefully sampled random accrual times we performed a standardized, timed review of available health records, including accompanying transfer documents. We also interviewed consenting patients and substitute decision makers to compare available code status documents to their current wishes. RESULTS Code status documentation was unavailable within 15 minutes of ED arrival in most cases (54/85, or 63%). Retrieval time was under five minutes in the rest, especially when "one click deep" in the EHR. When interviewed, 20/32 (63%) expressed "do not resuscitate" wishes, 10 of whom had no supporting documentation. Patients from assisted-living (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.7-26) and long-term care facilities (OR 13; 95% CI, 2.5-65) were more likely to have a documented code status available compared to those living in the community. CONCLUSION The majority of patients with end-stage disease, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have code status documents readily available upon arrival to our tertiary care ED. Patients living in the community with advanced disease may be at higher risk for unwanted resuscitative efforts should they present to hospital in extremis. While easily retrievable code status documentation within the EHR shows promise, its accuracy and validity remain important considerations.
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Affiliation(s)
- Evan Russell
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada
| | - Andrew K Hall
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada
| | - Conor McKaigney
- University of Calgary, Department of Emergency Medicine, Calgary, Alberta, Canada
| | - Craig Goldie
- Queen's University, Department of Medicine, Division of Palliative Care, Kingston, Ontario, Canada
| | - Ingrid Harle
- Queen's University, Department of Medicine, Division of Palliative Care, Kingston, Ontario, Canada
| | - Marco L A Sivilotti
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada.,Queen's University, Department of Biomedical & Molecular Sciences, Kingston, Ontario, Canada
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8
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Al-Ansari A, Suroor S, AboSerea S, Abd-El-Gawad WM. Harmonising palliative care: a national survey to evaluate the knowledge and attitude of emergency physicians towards palliative care in Kuwait. BMJ Support Palliat Care 2020:bmjspcare-2019-002141. [PMID: 33168669 DOI: 10.1136/bmjspcare-2019-002141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 08/18/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIM Although the challenges of integrating palliative care practices across care settings are real and well recognised, to date little is known about palliative care practices of emergency physicians (EPs) in Kuwait. Therefore, this study aims to explore the attitude and knowledge of EPs in providing palliative care in all general hospitals in Kuwait. METHOD A cross-sectional survey was performed in the emergency rooms of all general hospitals in Kuwait using the Palliative Care Attitude and Knowledge Questionnaire. RESULTS Of the total number of physicians working in emergency rooms (n=156), 104 (66.67%) had completed the survey. 76.9% (n=80) of the EPs had an uncertain attitude towards palliative care. Most of the EPs (n=73, 70.28%) did not discuss the patients' need for palliative care either with the patients or with their families. Only 16 (15.4%) of the EPs responded correctly to most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge. Experience ≥11 years and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position and nationality (OR: 5.747 (CI 1.031 to 25.00), 1.458(CI 1.148 to 1.851); p values: 0.021, 0.002, respectively). CONCLUSIONS Despite recognising palliative care as an important competence, the majority of the EPs in Kuwait had uncertain attitude and poor knowledge towards palliative care. Efforts should be made to enhance physician training and provide palliative care resources to improve the quality of care given to patients visiting emergency departments.
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Affiliation(s)
- Ameena Al-Ansari
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Saleem Suroor
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Sobhi AboSerea
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Wafaa Mostafa Abd-El-Gawad
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
- Geriatrics and Gerontology Department, Ain Shams University, Cairo, Egypt
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9
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Myall M, May C, Richardson A, Bogle S, Campling N, Dace S, Lund S. Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency. J Health Organ Manag 2020; ahead-of-print. [PMID: 33103399 PMCID: PMC9251639 DOI: 10.1108/jhom-06-2020-0240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.Design/methodology/approachA qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.FindingsWhile each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.Practical implicationsThe paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.Originality/valueThe paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.
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Affiliation(s)
- Michelle Myall
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Carl May
- Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine
, London,
UK
| | - Alison Richardson
- School of Health Sciences,
University of Southampton
, Southampton,
UK
- Clinical Academic Facility, Southampton General Hospital,
University Hospital Southampton NHS Foundation Trust
, Southampton,
UK
| | - Sarah Bogle
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Natasha Campling
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Sally Dace
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Susi Lund
- School of Health Sciences,
University of Southampton
, Southampton,
UK
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10
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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11
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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12
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Hawkes CA, Fritz Z, Deas G, Ahmedzai SH, Richardson A, Pitcher D, Spiller J, Perkins GD. Development of the Recommended Summary Plan for eEmergency Care and Treatment (ReSPECT). Resuscitation 2020; 148:98-107. [PMID: 31945422 DOI: 10.1016/j.resuscitation.2020.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/03/2019] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) practice has been shown to be variable and sub-optimal. This paper describes the development of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). ReSPECT is a process which encourages shared understanding of a patient's condition and what outcomes they value and fear, before recording clinical recommendations about cardiopulmonary-resuscitation (CPR) within a broader plan for emergency care and treatment. METHODS ReSPECT was developed iteratively, with integral stakeholder engagement, informed by the Knowledge-to-Action cycle. Mixed methods included: synthesis of existing literature; a national online consultation exercise; cognitive interviews with users; a patient-public involvement (PPI) workshop and a usability pilot, to ensure acceptability by both patients and professionals. RESULTS The majority (89%) of consultation respondents supported the concept of emergency care and treatment plans. Key features identified in the evaluation and incorporated into ReSPECT were: The importance of discussions between patient and clinician to inform realistic treatment preferences and clarity in the resulting recommendations recorded by the clinician on the form. The process is compliant with UK mental capacity laws. Documentation should be recognised across all health and care settings. There should be opportunity for timely review based on individual need. CONCLUSION ReSPECT is designed to facilitate discussions about a person's preferences to inform emergency care and treatment plans (including CPR) for use across all health and care settings. It has been developed iteratively with a range of stakeholders. Further research will be needed to assess the influence of ReSPECT on patient-centred decisions, experience and health outcomes.
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Affiliation(s)
- Claire A Hawkes
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK
| | - Zoe Fritz
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, UK; Cambridge University Hospitals, UK
| | - Gavin Deas
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Sam H Ahmedzai
- National Institute for Health Research Clinical Research Network - Cancer Cluster, University of Leeds, UK
| | - Alison Richardson
- School of Health Sciences, University of Southampton & University Hospital Southampton NHS Foundation Trust, UK
| | - David Pitcher
- Resuscitation Council UK, 5th Floor, Tavistock House North, Tavistock Square, London, WC1H 9HR, UK
| | | | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK; University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK.
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Wang DH, Kuntz J, Aberger K, DeSandre P. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients in the Emergency Department. J Palliat Med 2019; 22:1597-1602. [DOI: 10.1089/jpm.2019.0251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David H. Wang
- Division of Palliative Medicine, Scripps Health, San Diego, California
| | - Joanne Kuntz
- Department of Emergency Medicine and Emory University School of Medicine, Atlanta, Georgia
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St. Joseph's Health, Paterson, New Jersey
| | - Paul DeSandre
- Department of Emergency Medicine and Emory University School of Medicine, Atlanta, Georgia
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
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Al-ansari AM, Suroor SN, Aboserea SM, Abd-el-gawad WM. Harmonizing Palliative Care: National Survey to Evaluate the Knowledge and Attitude of Emergency Physicians towards Palliative Care.. [DOI: 10.1101/19003939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background and AimAlthough the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians (EPs) and their accessibility to palliative care services in Kuwait. So the aim of this study was to explore the attitude, and knowledge encountered by EPs in providing palliative care in all general hospitals in Kuwait.MethodA cross-sectional survey was performed in the emergency rooms of all general hospitals in Kuwait using Palliative Care Attitude and Knowledge (PCAK) questionnaire.ResultsOf the total number of physicians working in emergency rooms (n=156), 104 (66.67%) had completed the survey. 76.9% (n=80) of the EPs had either uncertain attitude toward palliative care. Most of the EPs (n=73, 70.28%) didn’t discuss the need of the patients to palliative care either with the patients or their families. Only 16 (15.4%) of the EPs responded correctly to the most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge especially in the most effective management of refractory dysnea (n=18, 17.3%). Experience ≥ 11yrs and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position, and nationality [OR: 5.747 (CI: 1.031-25.00), 1.458(CI: 1.148-1.851); p-value: 0.021, 0.002 respectively]..ConclusionsDespite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude. Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.What this paper addsStudies proved that the emergency room may be a suitable place for early referral of patients who may benefit from palliative care especially old age to prevent upcoming undesired admissions and hospital deaths.The integration of palliative care concepts and consultation teams into emergency medicine may help to avoid unnecessary and burdensome treatments, tests, and procedures that are not aligned with patients’ goals of care.Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians and their accessibility to palliative care services in Kuwait.Recently, a newly developed tool called Palliative Care Attitude and Knowledge (PCAK) questionnaire was created to assess the attitude and knowledge of non-palliative physicians toward palliative care. So the aim of this study was to explore the attitude, and knowledge encountered by emergency physicians in providing palliative care using PCAK 8 in emergency departments in all generalStudies showed that early palliative care consultation was shown to improve quality of life for cancer patients and may even lengthen their survival.What this study addsDespite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude.Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.
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Nonstandard Advance Health Care Directives in Emergency Departments: Ethical and Legal Dilemma or Reality: A Narrative Review. Adv Emerg Nurs J 2019; 40:324-327. [PMID: 30365447 DOI: 10.1097/tme.0000000000000214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People have tattooed themselves for thousands of years, and it remains popular with various groups across mainstream society. Although many people choose tattoos that express their life philosophy, epic events in their life, or their personal mantra, the use of tattooing in medicine such as a "do not resuscitate" tattoo is increasingly becoming more common (; ). As these tattoos do not meet the legal requirements for an advance health directive, they are at best a guide to the person's wishes and at worst a useless, painful exercise. New technology such as "talking tattoos" or implantable microchips could conceivably be used to record either an audible advance health directive or directions for emergency responders to access an individual's advance health directive. This article discusses the ethical and legal implications of nonstandard advance health directive tattoos in emergency treatment situations.
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A Systematic Approach to Comfort Care Transitions in the Emergency Department. J Emerg Med 2018; 56:267-274. [PMID: 30600110 DOI: 10.1016/j.jemermed.2018.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress. OBJECTIVES To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient. METHODS Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients. DISCUSSION Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy. CONCLUSION Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.
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Abbott J. The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department. Ann Emerg Med 2018; 73:294-301. [PMID: 30503382 DOI: 10.1016/j.annemergmed.2018.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/06/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.
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Affiliation(s)
- Jean Abbott
- Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora, CO.
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Waldrop DP, McGinley JM, Dailey MW, Clemency B. Decision-Making in the Moments Before Death: Challenges in Prehospital Care. PREHOSP EMERG CARE 2018; 23:356-363. [DOI: 10.1080/10903127.2018.1518504] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
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Goldonowicz JM, Runyon MS, Bullard MJ. Palliative care in the emergency department: an educational investigation and intervention. BMC Palliat Care 2018. [PMID: 29514625 PMCID: PMC5842635 DOI: 10.1186/s12904-018-0293-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the value of a novel simulation-based palliative care educational intervention within an emergency medicine (EM) residency curriculum. METHODS A palliative care scenario was designed and implemented in the simulation program at an urban academic emergency department (ED) with a 3-year EM residency program. EM residents attended one of eight high-fidelity simulation sessions, in groups of 5-6. A standardized participant portrayed the patient's family member. One resident from each session managed the scenario while the others observed. A 45-min debriefing session and small group discussion followed the scenario, facilitated by an EM simulation faculty member and a resident investigator. Best practices in palliative care were highlighted along with focused learner performance feedback. Participants completed an anonymous pre/post education intervention survey. RESULTS Forty of 42 EM residents (95%) participated in the study. Confidence in implementing palliative care skills and perceived importance of palliative care improved after this educational intervention. Specifically, residents 1) felt EM physicians had an important role in palliative care, 2) had increased confidence in the ability to determine patient decision-making capacity, 3) had improved confidence in initiating palliative discussions/treatment, 4) believed palliative education was important in residency, and 5) felt simulation was an effective means to learn palliative care. Differences noted between PGY1 and PGY 3 training levels in survey responses disappeared post-intervention. Residents noted being most comfortable with delivering bad news and symptom management and least comfortable with disease prognostication. Residents reported time constraints and implementation logistics in the ED as the most challenging factors for palliative care initiation. CONCLUSION Our case-based simulation intervention was associated with an increase in both the perceived importance of ED palliative care and self-reported confidence in implementing palliative care skills. Time constraints and implementation logistics were rated as the most challenging factors for palliative care initiation in the ED.
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Affiliation(s)
- Jessica M Goldonowicz
- Department of Emergency Medicine, Carolinas Medical Center, Carolinas Healthcare System, 1000 Blythe Blvd., 3rd Floor MEB, Charlotte, NC, 28203, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Carolinas Healthcare System, 1000 Blythe Blvd., 3rd Floor MEB, Charlotte, NC, 28203, USA
| | - Mark J Bullard
- Department of Emergency Medicine, Carolinas Medical Center, Carolinas Healthcare System, 1000 Blythe Blvd., 3rd Floor MEB, Charlotte, NC, 28203, USA. .,Carolinas Simulation Center, Carolinas Healthcare System, Charlotte, USA.
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Díaz-Cortés MDM, Granero-Molina J, Hernández-Padilla JM, Pérez Rodríguez R, Correa Casado M, Fernández-Sola C. Promoting dignified end-of-life care in the emergency department: A qualitative study. Int Emerg Nurs 2018; 37:23-28. [DOI: 10.1016/j.ienj.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/11/2017] [Accepted: 05/28/2017] [Indexed: 10/19/2022]
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22
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Fernández-Sola C, Granero-Molina J, Díaz-Cortés MDM, Jiménez-López FR, Roman-López P, Saez-Molina E, Aranda-Torres CJ, Muñoz-Terrón JM, García-Caro MP, Hernández-Padilla JM. Characterization, conservation and loss of dignity at the end-of- life in the emergency department. A qualitative protocol. J Adv Nurs 2018; 74:1392-1401. [PMID: 29421848 DOI: 10.1111/jan.13536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Abstract
AIMS To explore and understand the experiences of terminally ill patients and their relatives regarding dignity during end-of-life care in the emergency department. BACKGROUND The respect given to the concept of dignity is significantly modifying the clinical relationship and the care framework involving the end-of-life patient in palliative care units, critical care units, hospices and their own homes. This situation is applicable to in-hospital emergency departments, where there is a lack of research which takes the experiences of end-of-life patients and their relatives into account. DESIGN A phenomenological qualitative study. METHODS The protocol was approved in December 2016 and will be carried out from December 2016-December 2020. The Gadamer's philosophical underpinnings will be used in the design and development of the study. The data collection will include participant observation techniques in the emergency department, in-depth interviews with terminally ill patients and focus groups with their relatives. For the data analysis, the field notes and verbatim transcriptions will be read and codified using ATLAS.ti software to search for emerging themes. DISCUSSION Emerging themes that contribute to comprehending the phenomenon of dignity in end-of-life care in the emergency department are expected to be found. This study's results could have important implications in the implementation of new interventions in emergency departments. These interventions would be focused on improving: the social acceptance of death, environmental conditions, promotion of autonomy and accompaniment and assumption (takeover) of dignified actions and attitudes (respect for human rights).
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Affiliation(s)
- Cayetano Fernández-Sola
- Department of Nursing Science, Physiotherapy and Medicine, Research Group of Health Sciences CTS-451, University of Almeria, Almería, Spain.,Faculty of Health Sciences, Universidad Autónoma de Chile, Temuco, Chile
| | - José Granero-Molina
- Department of Nursing Science, Physiotherapy and Medicine, Research Group of Health Sciences CTS-451, University of Almeria, Almería, Spain.,Faculty of Health Sciences, Universidad Autónoma de Chile, Temuco, Chile
| | - María Del Mar Díaz-Cortés
- Emergency Department, Hospital Torrecárdenas, Almería, Spain.,Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almería, Spain
| | - Francisca Rosa Jiménez-López
- Department of Nursing Science, Physiotherapy and Medicine, Research Group of Health Sciences CTS-451, University of Almeria, Almería, Spain
| | - Pablo Roman-López
- Department of Nursing, Physiotherapy and Medicine, University of Almeria, Almería, Spain.,Department of Nursing, Universitat Jaume I, Castellon, Spain
| | | | | | | | | | - José Manuel Hernández-Padilla
- Department of Nursing Science, Physiotherapy and Medicine, Research Group of Health Sciences CTS-451, University of Almeria, Almería, Spain.,Adult, Child and Midwifery Department, School of Health and Education, Middlesex University, London, UK
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Abstract
AbstractEthical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201–212.
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Stuart RB, Thielke S. Standardizing Protection of Patients' Rights From POLST to MOELI (Medical Orders for End-of-Life Intervention). J Am Med Dir Assoc 2017. [DOI: 10.1016/j.jamda.2017.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Guidelines for Emergency Physicians on the Interpretation of Physician Orders for Life-Sustaining Therapy (POLST). Ann Emerg Med 2017. [DOI: 10.1016/j.annemergmed.2017.04.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach. HEC Forum 2017; 28:339-354. [PMID: 27392597 DOI: 10.1007/s10730-016-9305-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.
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Nakagawa Y, Inokuchi S, Kobayashi N, Ohkubo Y. Do not attempt resuscitation order in Japan. Acute Med Surg 2017; 4:286-292. [PMID: 29123876 PMCID: PMC5674456 DOI: 10.1002/ams2.271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 01/30/2017] [Indexed: 11/24/2022] Open
Abstract
Aim In Japan, the do not attempt resuscitation (DNAR) order is practised routinely even though no related laws or guidelines exist. This study aimed to clarify the current status of DNAR, reveal existing DNAR‐related issues, and improve the application of DNAR. Methods A questionnaire survey of medical institutions in Kanagawa Prefecture (total population, 9,120,000) about the current status of DNAR was carried out. Results The results showed that DNAR has been practised at approximately 90% of the hospitals surveyed, but only about 30% have developed in‐hospital DNAR guidelines. Approximately 80% of the hospitals do not involve patients in the decision on their own DNAR orders. Because the DNAR order has not been legislated, it is often unclear whether to resuscitate patients when a request for an ambulance is made for a cardiac arrest at home. Conclusion It is necessary for prefectures, municipalities, and local medical control authorities to take the initiative in establishing an ordinance on DNAR orders and developing guidelines.
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Affiliation(s)
- Yoshihide Nakagawa
- Department of Emergency and Critical Care Medicine Tokai University School of Medicine Kanagawa Japan
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine Tokai University School of Medicine Kanagawa Japan
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Wang DH. Beyond Code Status: Palliative Care Begins in the Emergency Department. Ann Emerg Med 2017; 69:437-443. [DOI: 10.1016/j.annemergmed.2016.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Indexed: 11/29/2022]
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Abbott J. Understanding What People Intend: Is It Possible From Written Advance Directives? J Am Med Dir Assoc 2017; 18:10-11. [DOI: 10.1016/j.jamda.2016.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 12/01/2022]
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Clemency B, Cordes CC, Lindstrom HA, Basior JM, Waldrop DP. Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care. J Am Med Dir Assoc 2016; 18:35-39. [PMID: 27692663 DOI: 10.1016/j.jamda.2016.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/29/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms. PROCEDURES MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis. RESULTS Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics. CONCLUSIONS Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.
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Affiliation(s)
- Brian Clemency
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
| | | | - Heather A Lindstrom
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
| | - Jeanne M Basior
- Department of Emergency Medicine, University at Buffalo School of Medicine, Buffalo, NY
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Abstract
Background: Respecting dignity is having a profound effect on the clinical relationship and the care framework for terminally ill patients in palliative care units, hospices and their own homes, with particular consequences for the emergency department. However, dignity is a vague and multifaceted concept that is difficult to measure. Objective: The aim of this study is to define the attributes of dignity in end-of-life care in the emergency department, based on the opinions of physicians and nurses. Research design: A hermeneutic phenomenological approach utilising Gadamer's philosophical underpinnings guided the study. Participants and research context: This research was conducted in Spain in 2013–2014. Participants included 10 physicians and 16 nurses with experience working in the emergency department. Two focus groups and 12 in-depth interviews were carried out. Ethical considerations: The study was approved by the Research Centre Ethical Committee (Andalusian Health Service, Spain). Findings: The results point to the person's inherent value, socio-environmental conditions and conscious actions/attitudes as attributes of dignity when caring for a dying patient in the emergency department. Discussion: Dying with dignity is a basic objective in end-of-life care and is an ambiguous but relevant concept for physicians and nurses. In line with our theoretical framework, our results highlight care environment, professional actions and socio-family context as attributes of dignity. Conclusion: Quality care in the emergency department includes paying attention to the dignity of people in the process of death. The dignity in the care of a dying person in the emergency department is defined by acknowledging the inherent value in each person, socio-environmental conditions and social and individual acceptance of death. Addressing these questions has significant repercussions for health professionals, especially nurses.
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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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Loss of Dignity in End-of-Life Care in the Emergency Department: A Phenomenological Study with Health Professionals. J Emerg Nurs 2016; 42:233-9. [PMID: 26972367 DOI: 10.1016/j.jen.2015.10.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/16/2015] [Accepted: 10/20/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The objective of this study was to explore and describe the experiences of physicians and nurses with regard to loss of dignity in relation to end-of-life care in the emergency department. METHOD A phenomenological qualitative study was performed. Two focus groups and 12 individual interviews were conducted with a total of 26 participants, who had attended to patients in the emergency department an average of 14.3 years. An inductive analysis was carried out with the use of ATLAS.ti software to seek emerging themes. RESULTS Three themes that helped us understand the phenomenon of the loss of dignity in end-of-life care in the emergency department emerged: (1) "Being exposed in a cold world," with the subthemes "improvising dying person care" and "a lack of space to care for the dying person"; (2) "Being self-critical with professional attitudes," with the subthemes "being aware of undignified actions" and "lack of a palliative culture"; and (3) "Family obstinacy and hospital rescue," with the subthemes "making ill-advised choices" and "avoiding burden." DISCUSSION The dignity of people who are taken to the emergency department at the end of their life could be undermined by architectural and organizational characteristics, professionals' attitudes, and decisions made by family members.
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Pirinea H, Simunich T, Wehner D, Ashurst J. Patient and Health-Care Provider Interpretation of do not Resuscitate and do not Intubate. Indian J Palliat Care 2016; 22:432-436. [PMID: 27803565 PMCID: PMC5072235 DOI: 10.4103/0973-1075.191784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Advance directives and end of life care are difficult discussions for both patients and health-care providers (HCPs). A HCP requires an accurate understanding of advanced directives to educate patients and their family members to allow them to make an appropriate decision. Misinterpretations of the do not resuscitate (DNR), do not intubate (DNI), and the Physicians Orders for Life-Sustaining Treatment (POLST) form result in ineffective communication and confusion between patients, family members, and HCPs. METHODOLOGY An anonymous, multiple choice online and paper survey was distributed to patients, family members of patients (PFMs), and HCPs from December 12, 2012 to March 6, 2013. Data regarding demographics, the accuracy of determining the correct definition of DNR and DNI, the familiarity of the POLST form and if a primary care physician had discussed advanced directives with the participants were collected. RESULTS A total of 687 respondents participated in the survey. Patients and PFMs could not distinguish the definition of DNR (95% confidence interval [CI] [1.453-2.804]) or DNI (95% CI (1.216-2.334)) 52% of the time while HCPs 35% and 39% of the time (P < 0.0005). Regarding the POLST form, 86% of patients and PFMs and 50% of HCPs were not familiar with the POLST form. Sixty-nine percent of patients and family members reported that their primary care physician had not discussed advance directives with them. Twenty-four percent of patients and family members reported that they had previous health-care experience and this was associated with increased knowledge of the POLST form (P < 0.0005). An association was also seen between the type of HCP taking the survey and the ability to correctly identify the correct definition of DNR (P < 0.0005). CONCLUSION Discussion of end of life care is difficult for patients and their family members. Often times multiple discussions are required in order to effectively communicate the definition of DNR, DNI, and the POLST form. Education of patients, family members, and HCPs is required to bridge the knowledge gap of advance directives.
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Affiliation(s)
- Heather Pirinea
- Department of Emergency Medicine, Memorial Medical Center, Johnstown, PA, USA
| | - Thomas Simunich
- Department of Research, Memorial Medical Center, Johnstown, PA, USA
| | - Daniel Wehner
- Department of Emergency Medicine, Memorial Medical Center, Johnstown, PA, USA
| | - John Ashurst
- Department of Emergency Medicine, Memorial Medical Center, Johnstown, PA, USA
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Affiliation(s)
- Eric M LeFebvre
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC.
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