Emergency physicians' role in end-of-life care

Palliative and end-of-life care education in Canadian emergency medicine residency programs: A national cross-sectional survey

Objectives

Emergency physicians play an important role in providing care at the end-of-life as well as identifying patients who may benefit from a palliative approach. Several studies have shown that emergency medicine (EM) residents desire further training in palliative care. We performed a national cross-sectional survey of EM program directors. Our primary objective was to describe the number of Canadian postgraduate EM training programs with palliative and end-of-life care curricula.

Methods

A 15-question survey in English and French was sent by email to all program directors of both the Canadian College of Family Physicians emergency medicine (CCFP(EM)) and the Royal College of Physicians and Surgeons of Canada emergency medicine (RCPSC-EM) postgraduate training programs countrywide using FluidSurveys™ with a modified Dillman approach.

Results

We received a total of 26 responses from the 36 (response rate = 72.2%) EM postgraduate programs in Canada. Ten out of 26 (38.5%) programs had a structured educational program pertaining to palliative and end-of-life care. Lectures or seminars were the exclusive choice to teach content. Clinical palliative medicine rotations were mandatory in one out of 26 (3.8%) programs. The top two barriers to implementation of palliative and end-of-life care curricula were lack of time (84.6%) and curriculum development concerns (80.8%).

Conclusions

Palliative and end-of-life care training within EM has been identified as an area of need. This cross-sectional survey demonstrates that a minority of Canadian EM programs have palliative and end-of-life care curricula. It will be important for all EM training programs, RCPSC-EM and CCFP(EM), in Canada, to develop an agreed upon set of competencies and to structure their curricula around them.

The Integration of Palliative Care into the Emergency Department

Palliative care (PC) is a new and developing area. It aims to provide the best possible quality of life for patients with life-limiting diseases. It does not primarily include life-extending therapies, but rather tries to help patients spend the rest of their lives in the best way. PC patients often are admitted to emergency departments during the course of a disease. The approach and management of PC include differences with emergency medicine. Thus, there are some problems while providing PC in the ED. With this article, the definition, main features, benefits, and problems of providing PC are presented, with the primary aim of emphasizing the importance of PC integration into the ED.

Physician Communication in Pediatric End-of-Life Care: A Simulation Study

OBJECTIVE

The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life.

METHODS

Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent.

RESULTS

Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely.

CONCLUSION

Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units.

PRACTICE IMPLICATIONS

The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.

Trajectories of approaching death in the emergency department: clinician narratives of patient transitions to the end of life

CONTEXT

Transitions near the end of life have not been well articulated and the end-of-life (EOL) phase is not well understood in the emergency department (ED). The sudden and unforeseen is common in the ED.

OBJECTIVES

The purpose of this qualitative research project is to identify different trajectories of approaching death in an effort to describe the EOL experience in the ED.

METHODS

An interpretive phenomenological approach was used to assess the results of interviews with and observations of ED staff who were intimately involved in caring for patients approaching death and dying.

RESULTS

Seven trajectories of approaching death in the ED emerged from the data: 1) dead on arrival; 2) prehospital resuscitation with subsequent ED death; 3) prehospital resuscitation with survival until admission; 4) terminally ill and comes to the ED; 5) frail and hovering near death; 6) alive and interactive on arrival, but arrests in the ED; and 7) potentially preventable death by omission or commission.

CONCLUSION

A descriptive articulation of the various trajectories will help clinicians be more astute in their recognition of the clinical situation and react appropriately, will help identify the transitions to the EOL phase, and will help to explore the possibilities open to the patient, family, and clinicians. In addition, understanding the trajectories and discussion of the clinicians' actions and communication strategies can elucidate which of the trajectories could benefit from anticipatory planning.

Resident perceptions of palliative care training in the emergency department

OBJECTIVES

To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents.

METHODS

This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training.

RESULTS

Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a "clear idea of the role of palliative care in EM." The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of self-reported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care.

CONCLUSIONS

New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training.

End-of-life decisions: family views on advance directives

A cross-sectional survey was administered to family members of patients who died at 1 of the 5 Catholic institutions comprising Mercy Health Partners, a health care system in Ohio, to determine their opinions about patient and family participation in decisions about end-of-life care. Among 165 respondents, 118 (86%) of 138 agreed that the family was encouraged to join in decisions and 133 (91%) of 146 that their family member's health care choices were followed. Most agreed that nurses answered their questions (93%, 141/151) and that the doctor communicated well with family members (83%, 128/155). Seventy percent (107/152) indicated that their family member had at least 1 advance directive. There were no differences in whether health care choices were followed when patients with formal advance directives (92%, 92/100) were compared with patients without formal advance directives (88%, 35/40). A unique survey instrument can be used to measure family perceptions and opinions of participation in decisions about end-of-life care.

Ethics seminars: withdrawal of treatment in the emergency department--when and how?

Although increasing discussion has occurred within emergency medicine about indications for withholding cardiac life support and other resuscitative interventions, emergency physicians (EPs) may be less familiar with the ethical, legal, and practical issues surrounding withdrawal of life support that has already been initiated. Both physicians and out-of-hospital personnel must act rapidly in critical situations and must assume that the patient has the desire to be resuscitated, unless clear evidence exists to the contrary. Often, only after initial life-saving actions have stabilized the patient is there time to reflect and determine a patient's desires regarding such interventions. When the EP can clearly discern a patient's previously stated wishes during the emergency department (ED) stay, these wishes should be honored in the ED. Respecting a patient's request to avoid unwanted, invasive treatments near death may involve withdrawing interventions that could not be withheld during the first few minutes of care. In this article, the authors use a case of out-of-hospital stabilization of a patient as a springboard to review the ethical and legal framework for withdrawal of life-sustaining care, as well as the practical issues involved with withdrawal of such care in the ED.

Death, dying, and last wishes

Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.

Resuscitation of the Elderly

The changing demographics of America's population over the past couple of decades have propelled geriatric medicine into the fore-front. Due to this, emergency medicine physicians will face numerous challenges managing an increasing number of critically ill elderly patients. This article will focus on success of resuscitation in this population, important pathophysiologic changes that occur with aging, as well as ethical considerations in end-of-life care.

End-of-life care: perspectives of family members of deceased patients

This study was undertaken to determine the opinions of family members of deceased patients regarding end-of-life care. This multisite cross-sectional survey was administered to 969 volunteer participants during 1997 to 2000. Eligible participants included immediate family members of deceased patients at five local institutions in a regional health system. Among 969 respondents, most (84.4 percent) indicated that the care for their family member was excellent. Reasons cited for satisfaction included overall care (40.2 percent), staff effort (23.2 percent), and communication (16.4 percent). Reasons cited for dissatisfaction included perceived incompetence (9.7 percent), perceived uncaring attitude (8.4 percent), and perceived understaffing (3.7 percent). Respondents were more satisfied with communication from nursing staff (88 percent) than physicians' communication (78 percent, p < 0.001, Bowker's test). Respondents indicated higher overall satisfaction with nursing (90 percent) and pastoral care (87 percent), than with physician care (81 percent, p < 0.001 and p = 0.006, Bowker's test). A unique survey instrument can be used to measure family perceptions and opinions regarding end-of-life care.

Intravenous fentanyl for cancer pain: a "fast titration" protocol for the emergency room

Patients with cancer sometimes are admitted to the emergency room due to severe pain. Despite the fact that morphine's hydrophilicity can delay its peak effects after intravenous administration up to 30 minutes, it is still the most commonly used opioid during cancer pain emergencies. Fentanyl is a synthetic, lipophilic opioid, more potent than morphine, and achieves peak effects after intravenous administration in 5 minutes. According to our observations, intravenous fentanyl could be safely used in the emergency room to treat patients who need fast titration of an opioid to control their pain. In our study, fentanyl was employed in a four-step protocol to treat patients admitted to our palliative care emergency room due to severe pain, regardless of the previous use of morphine at home. Titration with intravenous fentanyl was successfully employed in 18/18 (100%) of patients, with an average time for pain control at about 11 minutes, and without relevant adverse effects. We conclude that intravenous fentanyl could be safely used for severe cancer pain when rapid titration is being considered.