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Hauch H, El Mohaui N, Sander M, Rellensmann G, Berthold D, Kriwy P, Zernikow B, Wager J, Schneck E. Implementation and evaluation of a palliative care training unit for EMS providers. Front Pediatr 2023; 11:1272706. [PMID: 37830055 PMCID: PMC10565227 DOI: 10.3389/fped.2023.1272706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023] Open
Abstract
Background The prevalence of children with life-limiting conditions (LLCs) is rising. It is characteristic for these children to require 24/7 care. In emergencies, families must decide to call the emergency medical service (EMS) or a palliative care team (PCT)-if available. For EMS teams, an emergency in a child with an LLC is a rare event. Therefore, EMS providers asked for a training unit (TU) to improve their knowledge and skills in pediatric palliative care. Aim of the study The questions were as follows: whether a TU is feasible, whether its integration into the EMS training program was accepted, and whether an improvement of knowledge can be achieved. Methods We designed and implemented a brief TU based on findings of a previous study that included 1,005 EMS providers. The topics covered were: (1) basics in palliative home care, (2) theoretical aspects, and (3) practical aspects. After participating in the TU, the participants were given a questionnaire to re-evaluate their learning gains and self-confidence in dealing with emergencies in pediatric patients with LLC. Results 782 (77.8%) of 1,005 participants of the previous study responded to the questionnaire. The average age was 34.9 years (±10.7 years SD), and 75.3% were male. The average work experience was 11.4 years (±9.5 years SD), and 15.2% were medical doctors. We found an increase in theoretical knowledge and enhanced self-confidence in dealing with emergencies in patients with LLC (confidence: before training: 3.3 ± 2.0 SD; after training: 5.7 ± 2.1 SD; min.: 1; max.: 10; p < 0.001). The participants changed their approaches to a fictitious case report from more invasive to less invasive treatment. Most participants wanted to communicate directly with PCTs and demanded a standard operating procedure (SOP) for treating patients with LLC. We discussed a proposal for an SOP with the participants. Conclusion EMS providers want to be prepared for emergencies in children with LLCs. A brief TU can improve their knowledge and confidence to handle these situations adequately. This TU is the first step to improve collaboration between PCTs and EMS teams.
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Affiliation(s)
- Holger Hauch
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- Palliative Care Team for Children, University Children’s Hospital, Giessen, Hesse, Germany
| | - Naual El Mohaui
- Palliative Care Team for Children, University Children’s Hospital, Giessen, Hesse, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital, Giessen, Hesse, Germany
| | - Georg Rellensmann
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Daniel Berthold
- Department for Medical Oncology and Palliative Care, University Hospital of Giessen and Marburg, Giessen Site, Germany
| | - Peter Kriwy
- Institute for Sociology, Technical University of Chemnitz, Chemnitz, Saxony, Germany
| | - Boris Zernikow
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- PedScience Research Institute, Datteln, Germany
| | - Julia Wager
- Department of Children’s Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- PedScience Research Institute, Datteln, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital, Giessen, Hesse, Germany
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Breyre AM, Wang DH, Brooten JK, Colwell CB, Hanson KC, Taigman M, Lyng JW. EMS Care of Adult Hospice Patients- a Position Statement and Resource Document of NAEMSP and AAHPM. PREHOSP EMERG CARE 2023; 27:560-565. [PMID: 36961936 DOI: 10.1080/10903127.2023.2193978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Abstract
Emergency medical services (EMS) systems are designed to provide care in the field and while transporting patients to a hospital; however, patients enrolled in hospice may not want invasive therapies nor benefit from hospitalization. For many reasons, encounters with hospice patients can be challenging for EMS systems, EMS clinicians, hospice clinicians, hospice patients, and their families.
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Affiliation(s)
- Amelia M Breyre
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David H Wang
- Department of Palliative Medicine, Scripps Health, San Diego, California
| | - Justin K Brooten
- Department of Emergency Medicine & Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Christopher B Colwell
- Department of Emergency Medicine, University of California San Francisco Zuckerburg San Francisco General Hospital, San Francisco, California
| | - Kenneth C Hanson
- Department of Emergency Medicine, Central Michigan University College of Medicine-East Campus, Saginaw, Michigan
| | | | - John W Lyng
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota
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Gage CH, Stander C, Gwyther L, Stassen W. Emergency medical services and palliative care: a scoping review. BMJ Open 2023; 13:e071116. [PMID: 36927584 PMCID: PMC10030966 DOI: 10.1136/bmjopen-2022-071116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES The aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present? DESIGN A scoping review of literature was performed with an a priori search strategy. DATA SOURCES MEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Empirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. RESULTS In total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS' palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration. CONCLUSION EMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.
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Affiliation(s)
- Caleb Hanson Gage
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Charnelle Stander
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Liz Gwyther
- Division of Interdisciplinary Palliative Care and Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
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Wang DH, Breyre AM, Brooten JK, Hanson KC. Top Ten Tips Palliative Care Clinicians Should Know About Improving Partnerships with Emergency Medical Services. J Palliat Med 2023; 26:704-710. [PMID: 36607791 DOI: 10.1089/jpm.2022.0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Emergency medical services (EMS) clinicians increasingly encounter seriously ill patients and their caregivers in times of distress. When crises arise or care coordination falls short, these high-stakes interactions highlight opportunities to improve care experience and outcomes. Efforts must address wide educational gaps, absence of specialized care protocols, and systematic fragmentation leading to hyperlocal practice. The authors represent cross-sectional expertise in palliative care and EMS. This article describes unmet needs at the EMS-palliative interface, challenges with collaboration, and where directional progress exists.
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Affiliation(s)
- David H Wang
- Department of Palliative Medicine, Scripps Health, San Diego, California, USA
| | - Amelia M Breyre
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Justin K Brooten
- Department of Emergency Medicine and Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.,Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kenneth C Hanson
- Department of Emergency Medicine, Central Michigan University College of Medicine-East Campus, Saginaw, Michigan, USA
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Breyre AM, Sporer KA, Davenport G, Isaacs E, Glomb NW. Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions. BMC Emerg Med 2022; 22:145. [PMID: 35948964 PMCID: PMC9367154 DOI: 10.1186/s12873-022-00697-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.
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Affiliation(s)
- Amelia M Breyre
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA.
| | - Karl A Sporer
- Alameda County Emergency Medical Services Agency, San Leandro, USA
| | - Glen Davenport
- Columbia University, Columbia Center for Teaching and Learning, Oregon, USA
| | - Eric Isaacs
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
| | - Nicolaus W Glomb
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
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Wenger A, Potilechio M, Redinger K, Billian J, Aguilar J, Mastenbrook J. Care for a Dying Patient: EMS Perspectives on Caring for Hospice Patients. J Pain Symptom Manage 2022; 64:e71-e76. [PMID: 35490992 DOI: 10.1016/j.jpainsymman.2022.04.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT EMS providers frequently encounter patients in end-of-life situations. These situations can become ethically challenging depending on the nature of the event, availability of advance directives, and overall understanding of the situation by the patient and caregivers. This is particularly true for patients who are enrolled in Hospice, a specific form of end-of-life care available to patients with a terminal illness and expected lifespan of less than six months. OBJECTIVES This study aimed to survey the state of Michigan's EMS providers regarding encounters with hospice patients to better understand challenges caring for this population and to identify any need for additional education. METHODS An anonymous electronic survey was distributed via agency medical directors and a statewide listserv to all licensed EMS providers. Responses were collected via RedCap. Descriptive statistics were calculated. RESULTS A total of 706 responses were received. Most responses were from paramedics (55%) or EMTs (34%). 96% indicated having at least one encounter with a hospice patient and 66% had greater than 10 encounters. Only 24% had received formal education on the care of hospice patients. A high percentage (86%) indicated interest in additional training in this area. Challenges identified among providers were inaccessible advance directives (72%), pressure from family for more aggressive treatment (61%), and difficulty contacting hospice personnel (48%). CONCLUSION Educational gaps may be narrowed with additional end-of-life specific curricular components, with EMS providers expressing a strong desire for such training.
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Affiliation(s)
- Andrew Wenger
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA
| | - Megan Potilechio
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA
| | - Kathryn Redinger
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA.
| | - Joseph Billian
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA
| | - John Aguilar
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA
| | - Josh Mastenbrook
- Department of Palliative Care (A.W., M.P.), Northern Arizona Healthcare, Flagstaff, Arizona, USA; Department of Emergency Medicine (K.R., J.M.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Division of Epidemiology and Biostatistics (J.B.), Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA; Madison Emergency Physicians (J.A.), Madison, Wisconsin, USA
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Fitzpatrick S, Somers S, Stryckman B, Gingold DB. Improving Hospice and Palliative Care Through Nurse Practitioner Engagement in a Community Paramedicine Program. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Peran D, Uhlir M, Pekara J, Kolouch P, Loucka M. Approaching the End of Their Lives Under Blue Lights and Sirens - Scoping Review. J Pain Symptom Manage 2021; 62:1308-1318. [PMID: 33989706 DOI: 10.1016/j.jpainsymman.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Emergency medical services (EMS) are frequently responding to calls involving patients in advanced stages of incurable diseases. Despite the competencies and potential of EMS in supporting patients and their families facing symptoms of advanced progressive illnesses, the role of EMS in providing palliative care remains unclear. OBJECTIVE The following research question was formulated: What is the role of ambulance EMS, EMS dispatch centres, paramedics and emergency medical physicians in the provision of palliative care to terminally ill patients? METHODS Following PRISMA-ScR guidelines, online bibliographic databases CINAHL Complete, MEDLINE Complete (EBSCO), PubMed and MEDLINE (Ovid) were searched from the initial year of database to September 2019. No language restrictions were applied. RESULTS 31 articles were included in the qualitative synthesis and 3 main roles and one contextual factor were identified: (1) Providing complex care; (2) Adjusting patient's trajectory; (3) Being able to make decisions in a time and information limited environment; (4) Health care professionals are insufficiently supported in palliative care. CONCLUSION There are limited data on the incidence of EMS calls to the patients at the end-of-life and no data focusing on the EMS dispatch centres. Both paramedics and emergency physicians are aware of their role in the end-of-life care. EMS personnel are lacking special training and education in the palliative care. Cooperation between palliative care providers, the EMS providers and other out-of-hours services might improve the responsiveness of the health care system to needs and expectations of patients and their families, and possibly improve the overall health care system efficiency.
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Affiliation(s)
- David Peran
- Prague Emergency Medical Services, Prague, Czech Republic; Divisions of Public Health, 3rd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; Medical College, Prague, Czech Republic.
| | - Marek Uhlir
- Prague Emergency Medical Services, Prague, Czech Republic; Centre for Palliative Care, Prague, Czech Republic
| | - Jaroslav Pekara
- Prague Emergency Medical Services, Prague, Czech Republic; Medical College, Prague, Czech Republic
| | - Petr Kolouch
- Prague Emergency Medical Services, Prague, Czech Republic
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Breyre AM, Benesch T, Glomb NW, Sporer KA, Anderson WG. EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness. PREHOSP EMERG CARE 2021; 26:708-715. [PMID: 34669550 DOI: 10.1080/10903127.2021.1994674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.
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Breyre AM, Bains G, Moore J, Siegel L, Sporer KA. Hospice and Comfort Care Patient Utilization of Emergency Medical Services. J Palliat Med 2021; 25:259-264. [PMID: 34468199 DOI: 10.1089/jpm.2021.0143] [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] [Indexed: 11/13/2022] Open
Abstract
Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.
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Affiliation(s)
- Amelia M Breyre
- Department of Emergency Medicine and University California of San Francisco, San Francisco, California, USA
| | - Gurvijay Bains
- Department of Emergency Medicine, University California of San Francisco, San Francisco, California, USA
| | - Justin Moore
- Department of Emergency Medicine, Alameda Health System, Oakland, California, USA
| | - Lee Siegel
- Alameda County Emergency Medical Services, San Leandro, California, USA
| | - Karl A Sporer
- Alameda County Emergency Medical Services, San Leandro, California, USA
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Breyre A, Taigman M, Salvucci A, Sporer K. Effect of a Mobile Integrated Hospice Healthcare Program on Emergency Medical Services Transport to the Emergency Department. PREHOSP EMERG CARE 2021; 26:364-369. [PMID: 33689535 DOI: 10.1080/10903127.2021.1900474] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: To evaluate the effect of a Mobile Integrated Hospice Healthcare (MIHH) program including hospice education and expansion of paramedic scope of practice to use hospice medication kits. Primary outcome was the effect on hospice patient transport to the Emergency Department. Secondary outcomes included reasons for patient transport and review of MIHH kit utilization. Methods: In 2015, the project was implemented in Ventura County, California in collaboration with county emergency medical services (EMS) agency, first response/transport organizations, and hospice programs. Paramedic supervisors received 30 hours of hospice training focusing on palliative care, grief and crisis counseling. When 9-1-1 was called for a patient, EMS first responders arrived on scene, determined a patient was enrolled in hospice and then contacted trained MIHH. Results: Six months (2/2015-7/2015) prior to project implementation the percentage of hospice patients transported to the ED averaged 80.3% (98/122). During the first (8/2015-7/2016), second (8/2016-7/2017) and third year (8/2017-7/2018) after project implementation, the percentage of hospice patients transported to the ED was 36.2% (68/188), 33.2% (63/190) and 24.8% (36/145) respectively. A total of 523 hospice patients were cared for by MIHH during this three-year interval. Of those hospice patients transported, the most common reason for transport was fall/trauma. The MIHH hospice kit was only used once in the field. Odds ratio for hospice transportation to the ED before and after project implementation was 0.125 (95% Confidence Interval: 0.077 to 0.201; p < 0.0001). This represents an absolute reduction risk of 46.6% (95% Confidence Interval: 38.53% to 54.72%). Conclusion: MIHH decreased the transportation of hospice patients to the ED. MIHH provided hospice education, provided family grief support and developed treatment plans with hospice nurses. An expanded scope of practice, including a paramedic hospice kit, was not contributory to this decrease.
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Affiliation(s)
- Amelia Breyre
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California (AB); Healthcare Administration and Interprofessional Leadership, University of California San Francisco, San Francisco, California (MT); Ventura County Emergency Medical Services Agency, Oxnard, California (AS); University of California San Francisco, San Francisco, California (KS)
| | - Michael Taigman
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California (AB); Healthcare Administration and Interprofessional Leadership, University of California San Francisco, San Francisco, California (MT); Ventura County Emergency Medical Services Agency, Oxnard, California (AS); University of California San Francisco, San Francisco, California (KS)
| | - Angelo Salvucci
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California (AB); Healthcare Administration and Interprofessional Leadership, University of California San Francisco, San Francisco, California (MT); Ventura County Emergency Medical Services Agency, Oxnard, California (AS); University of California San Francisco, San Francisco, California (KS)
| | - Karl Sporer
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California (AB); Healthcare Administration and Interprofessional Leadership, University of California San Francisco, San Francisco, California (MT); Ventura County Emergency Medical Services Agency, Oxnard, California (AS); University of California San Francisco, San Francisco, California (KS)
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Waldrop DP, Waldrop MR, McGinley JM, Crowley CR, Clemency B. Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making. PREHOSP EMERG CARE 2021; 26:223-232. [PMID: 33320725 DOI: 10.1080/10903127.2020.1863532] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. Objective: The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician's Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. Methods: This study involved in-depth in-person interviews with 50 providers to elicit participants' experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Results: Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. Conclusions: The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.
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Affiliation(s)
- Deborah P Waldrop
- School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC)
| | - Michael R Waldrop
- School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC)
| | - Jacqueline M McGinley
- School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC)
| | - Charlotte R Crowley
- School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC)
| | - Brian Clemency
- School of Social Work, University at Buffalo, Buffalo, New York (DPW); Department of Emergency Medicine, Albany Medical Center, Albany, New York (MRW); College of Community & Public Affairs, Department of Social Work, Binghamton University, Binghamton, New York (JMM); Department of Emergency Medicine, University of Louisville, Louisville, Kentucky (CRC); Department of Emergency Medicine, University at Buffalo, Buffalo, New York (BC)
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13
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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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14
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Mills J. Ambulance Wish: An opportunity for public health palliative care partnerships with paramedics and other community members. PROGRESS IN PALLIATIVE CARE 2019. [DOI: 10.1080/09699260.2020.1695335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jason Mills
- Charles Darwin University, Brisbane, Australia
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15
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Stuart RB, Thielke S. Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation. J Am Med Dir Assoc 2019; 20:679-682. [PMID: 30826272 DOI: 10.1016/j.jamda.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 11/25/2022]
Abstract
Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.
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Affiliation(s)
- Richard B Stuart
- Swedish Edmonds Hospital, Samish Island Volunteer Fire Department, Bow, WA; Department of Psychiatry, University of Washington, Seattle, WA.
| | - Stephen Thielke
- Department of Psychiatry, University of Washington, Seattle, WA; Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA
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