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Pollack LR, Nomitch JT, Downey L, Paul SR, Reed MJ, Uyeda AM, Kiker WA, Dotolo DG, Dzeng E, Lee RY, Engelberg RA, Kross EK. Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care. J Pain Symptom Manage 2024; 68:142-152.e2. [PMID: 38685288 PMCID: PMC11239300 DOI: 10.1016/j.jpainsymman.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/07/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. OBJECTIVES To better understand decision-making regarding mechanical ventilation in people living with dementia. METHODS This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. RESULTS The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. CONCLUSION Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.
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Affiliation(s)
- Lauren R Pollack
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA.
| | - Jamie T Nomitch
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- University of Washington School of Medicine (S.R.P.), Seattle, Washington, USA
| | - May J Reed
- Division of Geriatric Medicine (M.J.R.), University of Washington, Seattle, Washington, USA
| | - Alison M Uyeda
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Whitney A Kiker
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Danae G Dotolo
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth Dzeng
- Department of Medicine (E.D.), University of California San Francisco, San Francisco, California, USA
| | - Robert Y Lee
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
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Juhrmann ML, Butow PN, Platts CM, Simpson P, Boughey M, Clayton JM. 'It breaks a narrative of paramedics, that we're lifesavers': A qualitative study of health professionals', bereaved family members' and carers' perceptions and experiences of palliative paramedicine. Palliat Med 2023; 37:1266-1279. [PMID: 37452564 PMCID: PMC10503236 DOI: 10.1177/02692163231186451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Paramedic practice is diversifying to accommodate evolving global health trends, including community paramedicine models and growing expertise in palliative and end-of-life care. However, despite palliative care specific clinical practice guidelines and existing training, paramedics still lack the skills, confidence and clinical support to provide this type of care. AIM To elicit paramedics', palliative care doctors and nurses', general practitioners', residential aged care nurses' and bereaved families and carers' experiences, perspectives, and attitudes on the role, barriers and enablers of paramedics delivering palliative and end-of-life care in community-based settings. DESIGN A qualitative study employing reflexive thematic analysis of data collected from semi-structured online interviews was utilised. SETTING/PARTICIPANTS A purposive sample of 50 stakeholders from all Australian jurisdictions participated. RESULTS Five themes were identified: positioning the paramedic (a dichotomy between the life saver and community responder); creating an identity (the trusted clinician in a crisis), fear and threat (feeling afraid of caring for the dying), permission to care (seeking consent to take a palliative approach) and the harsh reality (navigating the role in a limiting and siloed environment). CONCLUSION Paramedics were perceived to have a revered public identity, shaped by their ability to fix a crisis. However, paramedics and other health professionals also expressed fear and vulnerability when taking a palliative approach to care. Paramedics may require consent to move beyond a culture of curative care, yet all participant groups recognised their important adjunct role to support community-based palliative care.
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Affiliation(s)
- Madeleine L Juhrmann
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- The Palliative Centre, HammondCare, Greenwich Hospital, New South Wales, Australia
| | - Phyllis N Butow
- Chris O’Brien Lifehouse, School of Psychology, Faculty of Science, University of Sydney, New South Wales, Australia
| | - Cara M Platts
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
| | - Paul Simpson
- School of Paramedicine, Faculty of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Mark Boughey
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
- St Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Josephine M Clayton
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- The Palliative Centre, HammondCare, Greenwich Hospital, New South Wales, Australia
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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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Kangasniemi H, Setälä P, Huhtala H, Olkinuora A, Kämäräinen A, Virkkunen I, Tirkkonen J, Yli-Hankala A, Jämsen E, Hoppu S. Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings. Scand J Trauma Resusc Emerg Med 2022; 30:16. [PMID: 35264211 PMCID: PMC8905861 DOI: 10.1186/s13049-022-01002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/12/2022] [Indexed: 11/18/2022] Open
Abstract
Background We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). Methods A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. Results Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or ‘not eligible for intensive care’ (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. Conclusion Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01002-8.
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Affiliation(s)
- Heidi Kangasniemi
- Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland. .,Division of Anaesthesiology, Department of Perioperative, Intensive Care and Pain Medicine, HUS University of Helsinki and Helsinki University Hospital, Meilahti Tower Hospital, Haartmaninkatu 3, 00029, Helsinki, Finland. .,Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland. .,Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland.
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, P.O. Box 100, 33014, Tampere, Finland
| | - Anna Olkinuora
- Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland
| | - Antti Kämäräinen
- Department of Emergency Medicine, Hyvinkää Hospital, 05850, Hyvinkää, Finland
| | - Ilkka Virkkunen
- Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland.,Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
| | - Joonas Tirkkonen
- Department of Intensive Care Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
| | - Arvi Yli-Hankala
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland.,Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
| | - Esa Jämsen
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland.,Department of Geriatrics, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Centre for Prehospital Emergency Care, Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
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Juhrmann ML, Vandersman P, Butow PN, Clayton JM. Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis. Palliat Med 2022; 36:405-421. [PMID: 34852696 PMCID: PMC8972966 DOI: 10.1177/02692163211059342] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a growing demand for community palliative care and home-based deaths worldwide. However, gaps remain in this service provision, particularly after-hours. Paramedicine may help to bridge that gap and avoid unwanted hospital admissions, but a systematic overview of paramedics' potential role in palliative and end-of-life care is lacking. AIM To review and synthesise the empirical evidence regarding paramedics delivering palliative and end-of-life care in community-based settings. DESIGN A systematic integrative review with a thematic synthesis was undertaken in accordance with Whittemore and Knafl's methodology. Prospero: CRD4202119851. DATA SOURCES MEDLINE, CINAHL, PsycINFO and Scopus databases were searched in August 2020 for primary research articles published in English, with no date limits applied. Articles were screened and reviewed independently by two researchers, and quality appraisal was conducted following the Mixed-Methods Appraisal Tool (2018). RESULTS The search retrieved 5985 articles; 23 articles satisfied eligibility criteria, consisting of mixed-methods (n = 5), qualitative (n = 7), quantitative descriptive (n = 8) and quantitative non-randomised studies (n = 3). Through data analysis, three key themes were identified: (1) Broadening the traditional role, (2) Understanding patient wishes and (3) Supporting families. CONCLUSIONS Paramedics are a highly skilled workforce capable of helping to deliver palliative and end-of-life care to people in their homes and reducing avoidable hospital admissions, particularly for palliative emergencies. Future research should focus on investigating the efficacy of palliative care clinical practice guideline implementation for paramedics, understanding other healthcare professionals' perspectives, and undertaking health economic evaluations of targeted interventions.
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Affiliation(s)
- Madeleine L Juhrmann
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
| | - Priyanka Vandersman
- Research Centre for Palliative Care, Death and Dying, Flinders University of South Australia, Adelaide, SA, Australia
| | - Phyllis N Butow
- Psycho-oncology Co-operative Research Group and Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, NSW, Australia
| | - Josephine M Clayton
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
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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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Prachanukool T, Yuksen C, Jintanavasan S, Jenpanitpong C, Watcharakitpaisan S, Kaninworapan P, Maijan K. Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2021; 12:1111-1118. [PMID: 34616196 PMCID: PMC8487797 DOI: 10.2147/amep.s323557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/21/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Palliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients' needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work. METHODS This questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills. RESULTS Among 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006). CONCLUSION Our findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirada Jintanavasan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorawich Watcharakitpaisan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Parama Kaninworapan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Konwachira Maijan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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9
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Goodloe JM, Topjian A, Hsu A, Dunne R, Panchal AR, Levy M, McEvoy M, Vaillancourt C, Cabanas JG, Eisenberg MS, Rea TD, Kudenchuk PJ, Gienapp A, Flores GE, Fuchs S, Adelgais KM, Owusu-Ansah S, Terry M, Sawyer KN, Fromm P, Panczyk M, Kurz M, Lindbeck G, Tan DK, Edelson DP, Sayre MR. Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic. Circ Cardiovasc Qual Outcomes 2021; 14:e007666. [PMID: 34157848 PMCID: PMC8288195 DOI: 10.1161/circoutcomes.120.007666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa (J.M.G.)
| | - Alexis Topjian
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania (A.T.)
| | - Antony Hsu
- St Joseph Mercy Hospital, Ann Arbor, MI (A.H.)
| | - Robert Dunne
- Department of Emergency Medicine, St John Hospital, Detroit, MI (R.D.)
| | - Ashish R Panchal
- The Ohio State University Wexner Medical Center, Columbus (A.R.P.)
| | - Michael Levy
- University of Alaska Anchorage, Anchorage Areawide EMS (M.L.)
| | - Mike McEvoy
- EMS Coordinator - Saratoga County, NY (M.M.)
| | - Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (C.V.)
| | - Jose G Cabanas
- Wake County Department of Emergency Medical Services, University of North Carolina at Chapel Hill (J.G.C.)
| | - Mickey S Eisenberg
- Department of Emergency Medicine (M.S.E., M.R.S.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Thomas D Rea
- Department of Medicine (T.D.R.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Peter J Kudenchuk
- Division of Cardiology (P.J.K.).,University of Washington, Seattle. King County Emergency Medical Services, Seattle, WA (M.S.E., T.D.R., P.J.K.)
| | - Andy Gienapp
- Office of Emergency Medical Services, Wyoming Department of Health, Cheyenne (A.G.)
| | - Gustavo E Flores
- Emergency and Critical Care Trainings, San Juan, Puerto Rico (G.E.F.)
| | - Susan Fuchs
- Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital, Chicago, IL (S.F.)
| | - Kathleen M Adelgais
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora (K.M.A.)
| | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh (S.O.-A.), University of Pittsburgh School of Medicine, PA
| | - Mark Terry
- National Registry of Emergency Medical Technicians, Columbus, OH (M.T.)
| | - Kelly N Sawyer
- Department of Emergency Medicine (K.N.S.), University of Pittsburgh School of Medicine, PA
| | - Peter Fromm
- Mount Sinai South Nassau Hospital, Oceanside, NY (P.F.)
| | - Micah Panczyk
- University of Texas Health Science Center, Houston (M.P.)
| | | | - George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, Richmond (G.L.)
| | - David K Tan
- Washington University School of Medicine, St Louis, MO (D.K.T.)
| | | | - Michael R Sayre
- Department of Emergency Medicine (M.S.E., M.R.S.).,Seattle Fire Department, WA (M.R.S.)
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10
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Leggio WJ, Grawey T, Stilley J, Dorsett M. EMS Curriculum Should Educate Beyond a Technical Scope of Practice: Position Statement and Resource Document. PREHOSP EMERG CARE 2021; 25:724-729. [PMID: 33945384 DOI: 10.1080/10903127.2021.1925793] [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: 10/21/2022]
Abstract
Position Statement and Resource document approved by the NAEMSP Board of Directors on April 27, 2021.
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11
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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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12
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Counts CR, Blackwood J, Winchell R, Drucker C, Jennerich AL, Feder S, Pompeo K, Waldron J, Sayre MR, Kudenchuk PJ, Rea T. Emergency Medical Services and Do Not Attempt Resuscitation directives among patients with out-of-hospital cardiac arrest. Resuscitation 2020; 158:73-78. [PMID: 33221365 DOI: 10.1016/j.resuscitation.2020.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/17/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care. METHODS We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts. RESULTS Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05). Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison). CONCLUSIONS Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.
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Affiliation(s)
- Catherine R Counts
- Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States.
| | - Jennifer Blackwood
- Emergency Medical Services Division of Public Health - Seattle & King County, United States
| | - Ryan Winchell
- University of Washington School of Medicine, United States
| | - Christopher Drucker
- Emergency Medical Services Division of Public Health - Seattle & King County, United States
| | - Ann L Jennerich
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, United States
| | | | | | - Jody Waldron
- Department of Medicine, Division of General Medicine, University of Washington, United States
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States
| | - Peter J Kudenchuk
- Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of Cardiology, University of Washington, United States
| | - Thomas Rea
- Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of General Medicine, University of Washington, United States
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13
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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14
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Myall M, Rowsell A, Lund S, Turnbull J, Arber M, Crouch R, Pocock H, Deakin C, Richardson A. Death and dying in prehospital care: what are the experiences and issues for prehospital practitioners, families and bystanders? A scoping review. BMJ Open 2020; 10:e036925. [PMID: 32948555 PMCID: PMC7511644 DOI: 10.1136/bmjopen-2020-036925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To identify the factors that shape and characterise experiences of prehospital practitioners (PHPs), families and bystanders in the context of death and dying outside of the hospital environment where PHPs respond. DESIGN A scoping review using Arksey and O'Malley's five-stage framework. Papers were analysed using thematic analysis. DATA SOURCES MEDLINE; Embase; CINAHL; Scopus; Social Sciences Citation Index (Web of Science), ProQuest Dissertations & Theses A&I (Proquest), Health Technology Assessment database; PsycINFO; Grey Literature Report and PapersFirst were searched from January 2000 to May 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Qualitative and mixed methods studies reporting the experiences of PHPs, families and bystanders of death and dying in prehospital settings as a result of natural causes, trauma, suicide and homicide, >18 years of age, in Europe, USA, Canada, Australia and New Zealand. RESULTS Searches identified 15 352 papers of which 51 met the inclusion criteria. The review found substantial evidence of PHP experiences, except call handlers, and papers reporting family and bystander experiences were limited. PHP work was varied and complex, while confident in clinical work, they felt less equipped to deal with the emotion work, especially with an increasing role in palliative and end-of-life care. Families and bystanders reported generally positive experiences but their support needs were rarely explored. CONCLUSIONS To the best of our knowledge this is the first review that explores the experiences of PHPs, families and bystanders. An important outcome is identifying current gaps in knowledge where further empirical research is needed. The paucity of evidence suggested by this review on call handlers, families and bystanders presents opportunities to investigate their experiences in greater depth. Further research to address the current knowledge gaps will be important to inform future policy and practice.
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Affiliation(s)
- Michelle Myall
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Alison Rowsell
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Susi Lund
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Joanne Turnbull
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Mick Arber
- York Health Economics Consortium, University of York, York, North Yorkshire, UK
| | - Robert Crouch
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust Southern Headquarters, Otterbourne, Hampshire, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Charles Deakin
- South Central Ambulance Service NHS Foundation Trust Southern Headquarters, Otterbourne, Hampshire, UK
- NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, Hampshire, UK
| | - Alison Richardson
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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15
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Samuriwo R, Lovell-Smith C, Anstey S, Job C, Hopkinson J. Nurses' decision-making about cancer patients' end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol. BMJ Open 2020; 10:e034938. [PMID: 32624470 PMCID: PMC7337620 DOI: 10.1136/bmjopen-2019-034938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Patients with cancer are at high risk of developing pressure ulcers at the end of life as a result of their underlying condition or cancer treatment. There are many guidelines which set out best practice with regard to end-of-life skin care. However, the complexity of palliative cancer care often means that it is challenging for nurses to make the appropriate person-centred decisions about end-of-life skin care. This study seeks to explore the perceived importance that nurses place on different factors in their end-of-life skin care for patients with cancer. The utility, face validity and content validity of a prototype decision-making tool for end-of-life skin care will also be evaluated. METHODS AND ANALYSIS A mixed-method design will be used to gather data from primary and secondary care nurses working in different hospitals and local authority areas across Wales. Clinical vignettes will be used to gather qualitative and quantitative data from nurses in individual interviews. Qualitative data will be subject to thematic analysis and quantitative data will be subject to descriptive statistical analysis. Qualitative and quantitative data will then be synthesised, which will enhance the rigour of this study, and pertinently inform the further development of an end-of-life skin care decision-making tool for patients with cancer. ETHICS AND DISSEMINATION Ethical approval to undertake the study has been granted by Cardiff University School of Healthcare Sciences Research Governance and Ethics Screening Committee. Informed consent will be obtained in writing from all the participants in this study. The results of this study will be disseminated through journal articles, as well as presentations at national and international conferences. We will also report our findings to patient and public involvement groups with an interest in improving cancer care, palliative care as well as skin care.
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Affiliation(s)
- Ray Samuriwo
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
- Wales Centre for Evidence Based Care, School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | | | - Sally Anstey
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Claire Job
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Jane Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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