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Bourmorck D, Pétré B, de Saint-Hubert M, De Brauwer I. Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission. BMC Health Serv Res 2024; 24:773. [PMID: 38956595 PMCID: PMC11218079 DOI: 10.1186/s12913-024-11242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population. METHODS We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis. RESULTS Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile. CONCLUSIONS Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.
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Affiliation(s)
- Delphine Bourmorck
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
| | - Benoit Pétré
- Department of Public Health Sciences, Faculty of Medecine, University of Liège, Liège, Belgium
| | - Marie de Saint-Hubert
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- CHU-UCL Namur, Yvoir, Belgium
| | - Isabelle De Brauwer
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Department of Geriatric Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Karim R, Saheed M, Kies J, Churchill M, Vemula B, Doberman DJ. Feasibility of a Two-Step Palliative Screening Utilizing Existing Emergency Department Resources. J Pain Symptom Manage 2024; 67:e417-e424. [PMID: 38369250 DOI: 10.1016/j.jpainsymman.2024.02.002] [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: 12/03/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Although the Emergency Department (ED) offers a unique setting to provide early palliative care, staffing limitations curtail hospitals from establishing ED-palliative partnerships. MEASURES Feasibility of a two-step ED-palliative screening protocol was defined by two criteria: a ≥ 50% increase in palliative consults originating from the ED and a ≥ 50% consultation completion rate for patients who screened positive for unmet palliative needs. INTERVENTION A clinical decision support tool identified patients with treatment/code status limitations and prompted a care coordination referral. Care coordinators screened patients for unmet palliative needs using a content-validated screening tool and consulted palliative care for positive screens. OUTCOME Palliative care consultations originating from the ED increased by 110% from 32 to 67 consultations, and 57% (40/70) of patients who screened positive for unmet palliative needs received a consultation. CONCLUSIONS/LESSONS LEARNED Our project demonstrated feasibility of a two-step ED-palliative protocol by increasing palliative care consultation without necessitating additional staff.
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Affiliation(s)
- Razeen Karim
- Department of Medicine (R.K., J.K., M.C., B.V., D.D.), Section of Palliative Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Mustapha Saheed
- Department of Emergency Medicine (M.S., B.V.), The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamison Kies
- Department of Medicine (R.K., J.K., M.C., B.V., D.D.), Section of Palliative Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle Churchill
- Department of Medicine (R.K., J.K., M.C., B.V., D.D.), Section of Palliative Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Balakrishna Vemula
- Department of Medicine (R.K., J.K., M.C., B.V., D.D.), Section of Palliative Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Emergency Medicine (M.S., B.V.), The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Danielle J Doberman
- Department of Medicine (R.K., J.K., M.C., B.V., D.D.), Section of Palliative Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bayuo J, Kyei Baffour P. Healthcare Staff Perceptions Regarding Barriers and Enablers to End-of-Life Care Provision in Non-Palliative Care Settings in Ghana: A Multicentre Qualitative Study. OMEGA-JOURNAL OF DEATH AND DYING 2024; 89:259-274. [PMID: 35090354 DOI: 10.1177/00302228211072970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The projected rise in health-related suffering warrants the integration of palliative care across all health systems. For traditionally non-palliative care settings, barriers and enablers to palliative care integration remain poorly understood. This study sought to explore these barriers and enablers in the Emergency and Burn Units across two healthcare facilities in the middle belt of Ghana using qualitative description. Thirty-nine healthcare staff comprising 20 burn care staff and 19 ED staff were purposively recruited and interviewed. Interviews were transcribed following which thematic analysis was performed inductively. Two themes and six subthemes emerged from the data. The Ghanaian socio-cultural context often crippled the discussion of death and dying. Overall, there is a perceived tension between emergency/burns and end-of-life care. Opportunities however exist to improve the situation which will require more work regarding curricula improvement, providing avenues for professional development, culturally sensitive communication, and identifying strategies of engaging relatives.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
- Department of Nursing, Presbyterian University College, Ghana
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Adeyemi O, Walker L, Bermudez E, Cuthel AM, Zhao N, Siman N, Goldfeld K, Brody AA, Bouillon-Minois JB, DiMaggio C, Chodosh J, Grudzen CR. Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis. J Emerg Nurs 2024; 50:225-242. [PMID: 37966418 PMCID: PMC10939973 DOI: 10.1016/j.jen.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.
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Affiliation(s)
- Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | | | | | - Allison M. Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Nicole Zhao
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook NY
| | - Nina Siman
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Keith Goldfeld
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Emergency Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles DiMaggio
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
| | - Joshua Chodosh
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
- New York University Grossman School of Medicine, Department of Medicine, New York, New York, USA
| | - Corita R. Grudzen
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Wang YJ, Hsu CY, Yen AMF, Chen HH, Lai CC. Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department. BMC Palliat Care 2024; 23:51. [PMID: 38389106 PMCID: PMC10885365 DOI: 10.1186/s12904-024-01391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired. METHODS We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year. RESULTS A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic. CONCLUSIONS The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.
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Affiliation(s)
- Yu-Jing Wang
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
- Medical Department, Daichung Hospital, Miaoli, Taiwan
- Taiwan Association of Medical Screening, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan.
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan.
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Silva RS, Barbosa LC, Brandão MAG, Carneiro RDS, Félix NDDC, Alves MB. Geropalliative Caring Model analysis and assessment according to Fawcett's criteria. Rev Esc Enferm USP 2024; 57:e20230288. [PMID: 38411456 PMCID: PMC10890787 DOI: 10.1590/1980-220x-reeusp-2023-0288en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/28/2023] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES To analyze and assess Lee Geropaliative Caring Model according to Fawcett's criteria. METHOD A theoretical-reflective study about the Geropaliative Caring Model. The analysis resulted in a detailed review of the scope, context and content of a situation-specific theory, in order to determine aspects related to nursing practice and research, and assessment addressed the concrete concepts developed in theory, their significance, internal consistency, parsimony, testability and empirical and pragmatic adequacy in nursing as a discipline. RESULTS Based on the analysis, a situation-specific theory was used based on the science of care and aimed at caring for older adults undergoing palliation and their families, structured into four fields, namely: (1) aligning care; (2) keeping safe; (3) comforting body/mind/spirit; and (4) facilitating transitions. FINAL CONSIDERATIONS The analyzed and assessed theory leads to a structure that includes well-defined, delimited and interrelated concepts, based on the science of care as a grand theory that allowed Geropaliative Care Model derivation.
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Affiliation(s)
- Rudval Souza Silva
- Universidade do Estado da Bahia, Colegiado de Enfermagem, Senhor do Bonfim, BA, Brazil
- Universidade Federal da Bahia, Programa de Pós-graduação em Enfermagem e Saúde, Salvador, BA, Brazil
| | - Larissa Coelho Barbosa
- Universidade Federal da Bahia, Programa de Pós-graduação em Enfermagem e Saúde, Salvador, BA, Brazil
| | | | | | | | - Manuela Bastos Alves
- Universidade do Estado da Bahia, Colegiado de Enfermagem, Senhor do Bonfim, BA, Brazil
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Adeyemi O, Ginsburg AD, Kaur R, Cuthel AM, Zhao N, Siman N, Goldfeld KS, Emlet LL, DiMaggio C, Yamarik RL, Bouillon-Minois JB, Chodosh J, Grudzen CR. Serious illness communication skills training for emergency physicians and advanced practice providers: a multi-method assessment of the reach and effectiveness of the intervention. BMC Palliat Care 2024; 23:48. [PMID: 38378532 PMCID: PMC10880358 DOI: 10.1186/s12904-024-01349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 01/08/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND EM Talk is a communication skills training program designed to improve emergency providers' serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness. METHODS EM Talk consisted of one 4-h training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients' goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses. RESULTS A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63 to 100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of Serious Illness (SI) communication skills, improved attitude toward engaging qualifying patients in SI conversations, and commitment to using these learned skills in clinical practice. CONCLUSION Our study showed the extensive reach and the effectiveness of the EM Talk training in improving SI conversation. EM Talk, therefore, can potentially improve emergency providers' knowledge, attitude, and practice of SI communication skills. TRIAL REGISTRATION Clinicaltrials.gov: NCT03424109; Registered on January 30, 2018.
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Affiliation(s)
- Oluwaseun Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, 227 East 30thStreet, New York, NY, 10016, USA
| | | | | | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, 227 East 30thStreet, New York, NY, 10016, USA.
| | - Nicole Zhao
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, 227 East 30thStreet, New York, NY, 10016, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Nina Siman
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, 227 East 30thStreet, New York, NY, 10016, USA
| | - Keith S Goldfeld
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Lillian Liang Emlet
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles DiMaggio
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | | | - Joshua Chodosh
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Veteran's Affair, New York Harbor Healthcare System, New York, NY, USA
| | - Corita R Grudzen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Chang A, Espinosa J, Lucerna A. Emergency Department Management of Common End-of-Life and Palliative Care Symptoms: Three Cases. Cureus 2024; 16:e53538. [PMID: 38445127 PMCID: PMC10912970 DOI: 10.7759/cureus.53538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/07/2024] Open
Abstract
The emergency department (ED) is at times the only place where patients can turn for symptom relief. Patients of all ages may turn to the ED for help with the management of end-of-life (EOL) and palliative care (PC) symptoms. Emergency medicine (EM) is a specialty that manages disease-directed treatment for a variety of acute conditions. In contrast, EOL and PC are focused on improving quality of life. Patients with serious illness, even hospice patients, present to the ED in increasing numbers for symptom management. It has become essential for emergency physicians to care for patients who are not seeking life-sustaining measures but instead need quality-of-life interventions. The development of a clear, concise review of the most common acute symptoms can provide a framework for EM physicians to adequately address the needs of patients at the EOL. Here, we discuss three cases that highlight the management of five of the most common EOL and PC presentations to the ED.
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Affiliation(s)
- Alice Chang
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
| | - James Espinosa
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
| | - Alan Lucerna
- Emergency Medicine, Jefferson Health New Jersey, Stratford, USA
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Sweeny AL, Alsaba N, Grealish L, May K, Huang YL, Ranse J, Denny KJ, Lukin B, Broadbent A, Burrows E, Ranse K, Sunny L, Khatri M, Crilly J. End-of-life care: A retrospective cohort study of older people who died within 48 hours of presentation to the emergency department. Emerg Med Australas 2024; 36:13-23. [PMID: 37914673 DOI: 10.1111/1742-6723.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/06/2023] [Accepted: 09/27/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES To describe the characteristics of, and care provided to, older people who died within 48 h of ED presentation. METHODS A descriptive retrospective cohort study of people 65 years and older presenting to two EDs in Queensland, Australia, between April 2018 and March 2019. Data from electronic medical records were collected and analysed. RESULTS Two hundred and ninety-five older people who died within 48 h of ED presentation were included. Nearly all arrived by ambulance (92%, n = 272) and 36% (n = 106) were from aged care facilities. Three-quarters (75%, n = 222) were triaged into the most urgent triage categories (i.e. Australasian Triage Scale; ATS 1/2). Fewer than half were previously independent with mobility (38%, n = 111) and activities of daily living (43%, n = 128). Sixty-one per cent (n = 181) had a pre-existing healthcare directive. Twenty-two per cent (n = 66) died in ED, most commonly due to pneumonia, intracerebral haemorrhage, cardiac arrest and/or sepsis. Over half had one or more ED visits (52%, n = 154) and/or hospital admissions (52%, n = 152) 6 months prior. CONCLUSIONS Identification of patients at end-of-life (EoL) is not always straightforward; consider recent reduction in independence and recent ED visits/hospital admissions. System-based strategies that span pre-hospital, ED and in-patient care are recommended to facilitate EoL pathway implementation and care continuity.
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Affiliation(s)
- Amy L Sweeny
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Nemat Alsaba
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Laurie Grealish
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Nursing and Midwifery Research Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Katya May
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Ya-Ling Huang
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health (Nursing), Southern Cross University, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Kerina J Denny
- Department of Intensive Care Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Bill Lukin
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane Residential Aged Care Assessment and Referral Service, Brisbane, Queensland, Australia
| | - Andrew Broadbent
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Supportive and Specialist Palliative Care, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Erin Burrows
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Kristen Ranse
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Linda Sunny
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Lyell McEwin and Modbury Hospitals, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Meghna Khatri
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Emergency Department, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
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Adeyemi OJ, Siman N, Goldfeld KS, Cuthel AM, Bouillon-Minois JB, Grudzen CR. Emergency Providers' Knowledge and Attitudes Toward Hospice and Palliative Care: A Cross-Sectional Analysis Across 35 Emergency Departments in the United States. J Palliat Med 2023; 26:1252-1260. [PMID: 37262130 PMCID: PMC10623080 DOI: 10.1089/jpm.2022.0545] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Emergency providers' knowledge and attitudes may be a barrier to adopting hospice and palliative care practice. Objective: To assess provider characteristics associated with knowledge and attitudes toward hospice and palliative care (KAHP). Design: Cross-sectional analysis. Setting/Subjects: Emergency physicians, advanced practice providers (APPs), and nurses from 35 U.S. emergency departments (EDs) enrolled in a provider-focused intervention. Measurement: The outcome measures were the total and subscale scores of the KAHP scale. The predictor variables were age, sex, race/ethnicity, and years of practice. We reported the observed association using a linear mixed-effects regression model. Results: The mean KAHP score, rated from 10 to 50, was 36. Increased years of practice were associated with increased mean self-reported knowledge and attitudes scores among APPs and nurses. Conclusion: Understanding the provider characteristics associated with hospice and palliative care adoption in the ED may inform the development of interventions for specific providers. ClinicalTrials.gov (NCT03424109).
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Affiliation(s)
- Oluwaseun John Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nina Siman
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Keith S. Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Allison M. Cuthel
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Jean-Baptiste Bouillon-Minois
- Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Emergency Medicine, F-63000 Clermont-Ferrand, France
| | - Corita R. Grudzen
- Division of Supportive and Acute Care Services, Department of Medicine; Fern Grayer Chair in Oncology and Patient Experience, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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11
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Ohana S, Shaulov A, DeKeyser Ganz F. Acute palliative care models: scoping review. BMJ Support Palliat Care 2023:spcare-2022-004124. [PMID: 37591691 DOI: 10.1136/spcare-2022-004124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE The goal of this scoping review is to identify the most commonly used models of palliative care delivery in acute care settings, their advantages and disadvantages, and to review existent research evidence in support of each model. METHODS We conducted an extensive search using EMBASE, Medline, CINAHL and Pubmed, using various combinations of terms relating to models in palliative care and acute care settings. Data were analysed using tabular summaries and content analysis. RESULTS 41 articles were analysed. Four models were identified: primary, consultative, integrative and hybrid models of palliative care. All four models have varying characteristics in terms of access to specialist palliative care; fragmentation of healthcare services; therapeutic relationships between patients and providers; optimal usage of scarce palliative care resources; timing of provision of palliative care; communication and collaboration between providers and clarity of provider roles. Moreover, all four models have different patient outcomes and healthcare utilisation. Gaps in research limit the ability to determine what model of care is more applicable in an acute care setting. CONCLUSION No ideal model of care was identified. Each model had its advantages and disadvantages. Future work is needed to investigate which setting one model may be better than the other.
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Affiliation(s)
- Shulamit Ohana
- Nursing, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Adir Shaulov
- Nursing, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Freda DeKeyser Ganz
- Nursing, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
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12
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Adeyemi O, Ginsburg AD, Kaur R, Cuthel A, Zhao N, Siman N, Goldfeld K, Emlet LL, DiMaggio C, Yamarik R, Bouillon-Minois JB, Chodosh J, Grudzen CR. Serious Illness Communication Skills Training for Emergency Physicians and Advanced Practice Providers: A Multi-Method Assessment of the Reach and Effectiveness of the Intervention. RESEARCH SQUARE 2023:rs.3.rs-2561749. [PMID: 36865121 PMCID: PMC9980220 DOI: 10.21203/rs.3.rs-2561749/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Background EM Talk is a communication skills training program designed to improve emergency providers' serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness. Methods EM Talk is one of the components of Primary Palliative Care for Emergency Medicine (EM) intervention. It consisted of one 4-hour training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients' goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses. Results A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63-100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of discussion tips and tricks, improved attitude toward engaging qualifying patients in serious illness (SI) conversations, and commitment to using these learned skills in clinical practice. Conclusion Effectively engaging qualifying patients in serious illness conversations requires appropriate communication skills. EM Talk has the potential to improve emergency providers' knowledge, attitude, and practice of SI communication skills. Trial registration NCT03424109.
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13
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Neugarten C, Stanley M, Erickson S, Baldeo R, Aaronson E. Emergency Department Clinician Experience with Embedded Palliative Care. J Palliat Med 2023; 26:191-198. [PMID: 36074083 DOI: 10.1089/jpm.2022.0106] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background: While the benefits of embedding palliative care (PC) clinicians into the emergency department (ED) are now more widely appreciated, only a handful of programs have been reported in the literature. None has previously evaluated the attitudes and experiences of the multidisciplinary ED team with such an intervention. Objectives: We evaluated the experience of ED attendings, residents, nurses, social workers, and chaplains with an embedded PC clinician in the ED. Design/Subjects: We embedded PC clinicians into an urban, academic ED in the United States and surveyed 142 ED clinicians about their experiences. We analyzed survey results using descriptive analysis for closed-ended responses and thematic analyses for open-ended responses. Measurements/Results: One hundred six of 141 clinicians responded (75% response rate). Quantitative analysis found that 99% of participants found the program valuable. Benefits of embedded PC included changing patients' management or care trajectory, freeing up ED providers for other tasks, contributing to provider education, helping providers feel more supported during their shifts, and adding to providers' skill sets and confidence in practicing primary PC. Most participants reported minimal barriers to engaging with PC. The qualitative analysis identified program approval, desire for expansion/continuation of the program, and ongoing education of ED staff. Important themes for future programs include staff education, PC proactivity, importance of adapting to the needs of the ED, and education regarding PC consultation criteria. Conclusions: ED clinicians' attitudes toward embedded PC reflected overall approval, with underlying themes of providers feeling more supported during their shifts, improved resource management, the perception of better patient care, and nursing empowerment.
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Affiliation(s)
- Carter Neugarten
- Departments of Internal Medicine and Emergency Medicine, Rush University, Chicago, Illinois, USA
| | - Mary Stanley
- Rush University School of Medicine, Chicago, Illinois, USA
| | | | - Ryan Baldeo
- Department of Internal Medicine, Division of Palliative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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14
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Gunaga S, Zygowiec J. Primary Palliative Care in the Emergency Department and Acute Care Setting. Cancer Treat Res 2023; 187:115-135. [PMID: 37851223 DOI: 10.1007/978-3-031-29923-0_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Amidst a global COVID pandemic, the palliative care community and healthcare systems around the country continue to explore opportunities to improve early patient and family access to end-of-life care resources. They need not look any further than the Emergency Departments (ED) located on their campuses and around their communities for this chance. As advances in medical therapies continue to extend disease specific life expectancies and as the American population continues to age, we will continue to see older adults with chronic medical illnesses visiting the ED in their final stages of life (Smith et al. in Health Aff (Millwood) 31(6):1277-1285, 2012; Albert et al. in NCHS Data Brief 130:1-8, 2013). If the ED is to continue to be the primary portal of hospital entry for patients requiring emergent care for acute and chronic terminal illnesses, then it stands to reason that it should also be equally prepared to provide the earliest access to palliative care and advance care planning resources for patients and families who may want and benefit from these services. This chapter will explore the unique horizon of opportunities that exist for emergency medicine and the palliative care specialty to fulfill this obligation. Discussion will be centered around core principles in screening, assessment, and management of palliative care needs in the ED, importance of goals of care conversations, and the coordination of early palliative care and hospice consults that can facilitate safe transitions of care.
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Affiliation(s)
- Satheesh Gunaga
- Henry Ford Wyandotte Hospital and Envision Healthcare, Wyandotte, MI, USA.
- Clinical Assistant Professor, Michigan State University College of Osteopathic Medicine, East Lansing, USA.
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15
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Kirkland SW, Yang EH, Garrido Clua M, Kruhlak M, Campbell S, Villa-Roel C, Rowe BH. Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review. Acad Emerg Med 2022; 29:1229-1246. [PMID: 35344239 DOI: 10.1111/acem.14492] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED). METHODS A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs). RESULTS A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%. CONCLUSIONS This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Orthopaedic Surgery, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Maureen Kruhlak
- School of Veterinary Medicine, St. George's University, West Indies, Grenada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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16
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Grudzen CR, Barker PC, Bischof JJ, Cuthel AM, Isaacs ED, Southerland LT, Yamarik RL. Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician. EMERGENCY CANCER CARE 2022; 1:10. [PMID: 35966217 PMCID: PMC9362452 DOI: 10.1186/s44201-022-00010-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.
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17
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Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness, Boston, Massachusetts, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason K Bowman
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne G Kuntz
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Karen Jubanyik
- Emergency Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leah E Bright
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric Isaacs
- Emergency Department, Zuckerberg San Francisco General Hospital, University of California at San Francisco, San Francisco, California, USA
| | - Laura A Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lauren LaPointe
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine, Seattle, Washington, USA
| | - Rita Manfredi
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC, USA
| | - Tammie Quest
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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18
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Nguyen D, Matese T. Assessing the Effect of a Hospice and Palliative Medicine Curriculum on Emergency Medicine Residents' Knowledge. Am J Hosp Palliat Care 2022; 40:462-467. [PMID: 35570823 DOI: 10.1177/10499091221102541] [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: 11/17/2022] Open
Abstract
Background: In the average Emergency Medicine (EM) residency program there is little formal Hospice and Palliative Medicine (HPM) training, despite these skills used frequency in the Emergency Department (ED) setting, from symptomatic management to end of life communications. Objective: This research project aims to determine if a Free Open Access Medical Education based HPM curriculum will improve knowledge and comfort level of end-of-life care in EM residents within the ED. The curriculum consisted of an in-person lecture series along with self-directed learning through online modules covering a variety of foundational topics. Methods: A 10-point Likert-scale pre- and post-intervention self-survey, assessing HPM comfort level and foundation/knowledge base and skills, was administered to the residents. Results: 16/18 residents (89%) responded to the pre-intervention survey and 13/18 residents (72%) answered the post-intervention survey. There was a statistically significant increase of the residents' understanding of the difference between hospice and palliative care (pre-intervention mean of 4.44, post-intervention mean of 7.69, P = .004), as well as their perspective of how often they consult those services for patients they see in the ED (pre-intervention mean of 2.19, post-intervention mean of 3.92, P = .02) and their overall understanding of the foundations of this field (pre-intervention mean of 4.19, post-intervention mean of 7.23, P = .0002). Conclusion: The curriculum increased the EM residents' understanding of the foundations of the HPM field, their fundamental knowledge of the differences between the 2 disciplines, and the frequency of how often they consult these specialties in the ED.
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Affiliation(s)
- David Nguyen
- St. Lucie Medical Center, Port St Lucie, FL, USA
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19
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Abstract
Background: Newly arriving Syrian refugees can present with specific health characteristics and medical conditions when entering the United States. Given the lack of epidemiological data available for the refugee populations, our study examined the demographic features of Syrian refugees resettled in the state of Kentucky. Specifically, we examined mental and physical health clinical data in both pre-departure health screenings and domestic Refugee Health Assessments (RHA; Kentucky Office for Refugees, n.d.) performed after resettlement. Method: The current study adopted a cross-sectional research design. We analyzed outcome data collected from participants from 2013 and 2015. Specifically, a comparative cross-sectional analysis was performed using clinical data from Syrian refugees who underwent an RHA as part of the resettlement process between January 2015 and August 2016. Those data were compared to data derived from refugees from other countries who resettled in Kentucky between 2013 and 2015. Results: Mental health screenings using the Refugee Health Screener (RHS-15; Hollifield et al., 2013) found that 19.5% (n = 34) of adult Syrian refugees reported signs and symptoms from posttraumatic stress, depressive symptoms, and/or anxiety, and nearly 40% (n = 69) reported personal experiences of imprisonment or violence, and/or having witnessed someone experiencing torture or violence. Intestinal parasites and lack of immunity to varicella were the most prevalent communicable diseases among Syrian refugees. Dental abnormalities and decreased visual acuity account for the first and second most prevalent non-communicable conditions. When comparing these results to all refugees arriving during the same years, significant differences arose in demographic variables, social history, communicable diseases, and non-communicable diseases. Conclusion: This study provides an initial health profile of Syrian refugees resettling in Kentucky, which reflects mental health as a major healthcare concern. Posttraumatic stress and related symptoms are severe mental health conditions among Syrian refugees above and beyond other severe physical problems.
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20
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Kirkland SW, Yang EH, Clua MG, Kruhlak M, Villa-Roel C, Elwi A, O'Neill B, Duggan S, Brisebois A, Stewart DA, Rowe BH. Comparison of the Management and Short-Term Outcomes between Patients with Advanced Cancer and Other End-of-Life Conditions Presenting to Two Canadian Emergency Departments. J Palliat Med 2022; 25:915-924. [PMID: 35119311 DOI: 10.1089/jpm.2021.0519] [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: 11/12/2022] Open
Abstract
Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March-August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maureen Kruhlak
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adam Elwi
- Department of Medicine and Palliative Care, Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
| | - Barbara O'Neill
- Department of Medicine and Palliative Care, Grey Nun Hospital, Covenant Health, Edmonton, Alberta, Canada
| | - Shelley Duggan
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Brisebois
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas A Stewart
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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21
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Casey MF, Price L, Markwalter D, Bohrmann T, Tsujimoto TM, Lavin K, Hanson LC, Lin FC, Platts-Mills TF. Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program. Am J Hosp Palliat Care 2022; 39:1358-1363. [PMID: 35040696 PMCID: PMC9289079 DOI: 10.1177/10499091211072850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. Design This was an observational pre-/post-interventional study. Setting This study was conducted at a Southeastern U.S. academic ED. Participants 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. Interventions The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. Outcome measures The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. Results There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). Conclusion A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.
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Affiliation(s)
- Martin F Casey
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Laiken Price
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Daniel Markwalter
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Tamy Moraes Tsujimoto
- Department of Biostatistics, 6797University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, NC, USA
| | - Kyle Lavin
- Department of Psychiatry and UNC Palliative Care Program, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and UNC Palliative Care Program, Department of Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Feng-Chang Lin
- Department of Biostatistics, 6797University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, NC, USA
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22
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Nalugya LG, Harborne D, Reid E. Factors affecting initiation of palliative care in a Ugandan Emergency Department. Afr J Emerg Med 2021; 11:442-446. [PMID: 34765429 PMCID: PMC8568603 DOI: 10.1016/j.afjem.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/30/2021] [Accepted: 06/04/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The Emergency Department (ED) of Mbarara Regional Referral Hospital serves a largely rural population of 4 million people in western Uganda. Here, ED patients with incurable illness often have prolonged stays. Palliative care (PC) is a low-cost intervention that focuses on alleviating pain and suffering for patients with incurable disease, while improving satisfaction with care and optimizing healthcare utilization. This is especially important in low resource settings. A prior needs assessment in our ED revealed that 50% of patients have PC needs. The ED is an optimal location to initiate PC, yet this rarely happens. There is a great need to identify factors affecting initiation of ED PC in our resource-limited setting. Methods A semi-structured questionnaire and chart review was conducted from March to August 2020. Patients admitted from the ED were assessed for PC needs. Those who met criteria were approached for inclusion and flagged for initiation of PC. The follow-up period was 7 days. Results Sixty two percent of those subjects flagged for initiation of PC received it. By day seven, 36.1 of the study population had died. ED initiation of PC varied significantly by diagnosis, with cancer patients more likely to receive PC (p = 0.0097). Conclusion Important barriers to PC initiation were identified in our Ugandan ED, related to diagnosis. These barriers could be overcome by improving awareness of PC amongst patients and providers alike and implementing a PC screening tool for all admissions. Future research is needed to identify other barriers, as well as strategies for improved hospital-wide uptake of PC in this resource-limited setting.
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Bayuo J, Anago EK, Agyei FB, Salifu Y, Kyei Baffour P, Atta Poku C. "Resuscitate and Push": End-of-Life Care Experiences of Healthcare Staff in the Emergency Department - A Hermeneutic Phenomenological Study. J Palliat Care 2021; 37:494-502. [PMID: 34713731 DOI: 10.1177/08258597211050740] [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: 01/03/2023]
Abstract
OBJECTIVE Care in the emergency department focuses significantly on delivering lifesaving/ life-sustaining clinical actions, often with limited attention to health-related suffering even at the end-of-life. How healthcare staff experience and navigate through the end-of-life phase remains minimally explored. Thus, this study aimed to uncover the lived experiences of emergency department staff at the end-of-life. METHODS van Manen's hermeneutic phenomenological approach was used. Nineteen healthcare staff were purposively recruited and interviewed. Interviews were audio-taped, transcribed verbatim, and thematic categories formulated. The existential lifeworld themes (corporeality, relationality, spatiality, and temporality) were used as heuristic guides for reflecting and organizing the lived experiences of participants. RESULTS The overarching category, 'resuscitate and push', was captured as corporeality (resisting death and dying); relationality (connectedness to the body of the patient; and lacking support for family and self); spatiality (navigating through a liminal space and lack of privacy for patients); and temporality (having limited to no time for end-of-life care and grieving). The end-of-life space was unpleasant. Although participants experienced helplessness and feelings of failure, support systems to help them to navigate through these emotions were lacking. Grief was experienced covertly and concealed by the entry of a new patient. CONCLUSION End-of-life in the emergency department is poorly defined. In addition to shifting from the traditional emergency care model to support the streamlining of palliative care in the department, staff will require support with navigating through the liminal space, managing their grief, and developing a better working relationship with patients/ families.
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Affiliation(s)
- Jonathan Bayuo
- The Hong Kong Polytechnic University, Hung Hom, Hong Kong
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Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med 2021; 78:658-669. [PMID: 34353647 DOI: 10.1016/j.annemergmed.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.
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Affiliation(s)
- Anthony J Loffredo
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA
| | - David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, CA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Eric D Isaacs
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Rachel Pearl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Rosenberg
- Department of Emergency Medicine, St Joseph's Health, Paterson and Wayne, NJ
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St Joseph's Health, Paterson, NJ; Department of Emergency Medicine, Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
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Palliative care in the emergency department: A qualitative study exploring barriers, facilitators, desired clinician qualities, and future directions. Palliat Support Care 2021; 20:363-368. [PMID: 34233782 DOI: 10.1017/s1478951521001012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED-PC, and clinicians' perspectives on the future of ED-PC. METHOD This qualitative study using semi-structured interviews was conducted in June-August 2020. Interviews were analyzed via a two-phase Rapid Analysis. The study's primary outcomes (innovations in ED-PC during COVID) are published elsewhere. In this secondary analysis, we examine interviewee responses to broader questions about ED-PC currently and in the future. RESULTS PC providers perceived as successful in their work in the ED were described as autonomous, competent, flexible, fast, and fluent in ED language and culture. Barriers to ED-PC integration included the ED environment, lack of access to PC providers at all times, the ED perception of PC, and the lack of a supporting financial model. Facilitators to ED-PC integration included proactive identification of patients who would benefit from PC, ED-focused PC education and tools, PC presence in the ED, and data supporting ED-PC. Increased primary PC education for ED staff, increased automation, and innovative ED-PC models were seen as areas for future growth. SIGNIFICANCE OF RESULTS Our findings provide useful information for PC programs considering expanding their ED presence, particularly as this is the first study to our knowledge that examines traits of successful PC providers in the ED environment. Our findings also suggest that, despite growth in the arena of ED-PC, barriers and facilitators remain similar to those identified previously. Future research is needed to evaluate the impact that ED-PC initiatives may have on patient and system outcomes, to identify a financial model to maintain ED-PC integration, and to examine whether perceptions of successful providers align with objective measures of the same.
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Aaronson EL, Daubman BR, Petrillo L, Bowman J, Ouchi K, Gips A, Traeger L, Jackson V, Grudzen C, Ritchie CS. Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic. J Pain Symptom Manage 2021; 62:117-124. [PMID: 33161031 PMCID: PMC7645272 DOI: 10.1016/j.jpainsymman.2020.10.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. OBJECTIVES To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. METHODS For this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations. RESULTS Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories. CONCLUSION Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexa Gips
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Palliative Care Service, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lara Traeger
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Corita Grudzen
- Department of Emergency Medicine, NYU Langone Health/Bellevue Hospital Center, NYU Grossman School of Medicine, New York, USA
| | - Christine Seel Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
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Chang JCY, Yang C, Lai LL, Huang HH, Fan JS, Lin MH, Hsu TF, Yen DHT. Differences in end-of-life care and outcomes in palliative consultation-eligible patients with and without do-not-resuscitate orders: A propensity score-matched study. J Chin Med Assoc 2021; 84:633-639. [PMID: 33871389 DOI: 10.1097/jcma.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. METHODS This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. RESULTS A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). CONCLUSION The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.
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Affiliation(s)
- Julia Chia-Yu Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Ling Lai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Teh-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Emergency Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
- Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC
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Siegel M, Westlake E. Goals-of-Care Course for Emergency Physicians during the COVID-19 Pandemic. J Palliat Med 2021; 24:647-648. [PMID: 33761285 DOI: 10.1089/jpm.2021.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Mari Siegel
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Erica Westlake
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Wang RF, Lai CC, Fu PY, Huang YC, Huang SJ, Chu D, Lin SP, Chaou CH, Hsu CY, Chen HH. A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department. Palliat Med 2021; 35:408-416. [PMID: 33198575 DOI: 10.1177/0269216320972041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM We developed a screening model for predicting 1-year mortality. DESIGN A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.
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Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taipei
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
| | - Ping-Yeh Fu
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | | | | | - Dachen Chu
- Superintendent, Taipei City Hospital
- National Yang-Ming University, Taipei
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan City
| | - Chen-Yang Hsu
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
- Da-Chung Hospital, Miaoli
| | - Hsiu-Hsi Chen
- Division Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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Nurses Training and Capacitation for Palliative Care in Emergency Units: A Systematic Review. ACTA ACUST UNITED AC 2020; 56:medicina56120648. [PMID: 33256039 PMCID: PMC7759785 DOI: 10.3390/medicina56120648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022]
Abstract
Background and objectives: Palliative care (PC) prevents and alleviates patients´ suffering to improve their quality of life in their last days. In recent years, there has been an increase in visits to the emergency services (ES) by patients who may need this type of care. The aims were to describe the training and capacitation of nurses from ES in PC. Accordingly, a systematic review was performed. Materials and Methods: Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were used. The search equation was “Palliative care and nursing care and emergency room”. A total of 12 studies were selected. Results: The studies agree on the need for training professionals in PC to provide a higher quality care, better identification of patient needs and to avoid unnecessary invasive processes. Similarly, the implementation of a collaborative model between ES and PC, the existence of a PC specialized team in the ES or proper palliative care at home correspond to a decrease in emergency visits, a lower number of hospitalizations or days admitted, and a decrease in hospital deaths. Conclusions: The development of PC in the different areas of patient care is necessary. Better palliative care leads to a lower frequency of ES by terminal patients, which has a positive impact on their quality of life. Access to PC from the emergency unit should be one of the priority health objectives due to increment in the aged population susceptible to this type of care.
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Breakey N, Osterwalder J, Mathis G, Lehmann B, Sauter TC. Point of care ultrasound for rapid assessment and treatment of palliative care patients in acute medical settings. Eur J Intern Med 2020; 81:7-14. [PMID: 32807648 DOI: 10.1016/j.ejim.2020.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 07/09/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
The combination of an ageing population with improving survival in malignant and non-malignant disease processes results in a growing cohort of patients with advanced or end-stage chronic diseases who require acute medical care. Emergency care has historically been stereotyped as the identification and treatment of acute life-threatening problems. Although palliative care may be considered to be new to the formal curriculum of emergency medicine, in many domains the ultrasound skillset of a physician in acute medical care can be efficaciously deployed the benefit of patients with both malignant and non-malignant disease processes that require palliative care in the full breadth of acute healthcare settings. In diagnostic domains (abdominal pain, urinary tract obstruction, dyspnoea, venous thromboembolism and musculoskeletal pain) and for specific intervention guidance (thoracentesis, paracentesis, venous access, regional anaesthesia and musculoskeletal interventions) we suggest that POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications in this important patient population. POCUS is a mandatory competence in the European curriculum of internal medicine, and specific training programs which cover applications in the domains of palliative care in acute care settings are available. Supervision, quality assurance and appropriate documentation are required. We expect that as the availability of mobile units suitable for point of care applications increases, these applications should become standard of care in the acute management of patients who require palliative care.
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Affiliation(s)
- Neal Breakey
- Department of Medicine, Spital Emmental, Burgdorf, Switzerland; Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | | | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Medical Skills Lab, Charité Medical School Berlin, Berlin, Germany
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Stewart BT, Carrougher GJ, Curtis E, Schneider JC, Ryan CM, Amtmann D, Gibran NS. Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study. Burns 2020; 47:42-51. [PMID: 33092898 PMCID: PMC7533049 DOI: 10.1016/j.burns.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/20/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury. METHODS We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined. RESULTS The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r2 0.01-0.12). CONCLUSION Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.
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Affiliation(s)
- Barclay T Stewart
- Department of Surgery, University of Washington, Northwest Regional Burn Model System; Northwest Regional Burn Model System.
| | | | - Elleanor Curtis
- Department of Surgery, University of California Davis Health, Department of Palliative Care, University of California Davis Health
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston-Harvard Burn Injury Model System
| | - Colleen M Ryan
- Department of Surgery, Harvard Medical School, Boston-Harvard Burn Injury Model System
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Burn Model System
| | - Nicole S Gibran
- Department of Surgery, University of Washington, Northwest Regional Burn Model System; Northwest Regional Burn Model System
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Goh JL, Jaffar JLY, Xu H, Lum VWM. A retrospective study on end-of-life care in the emergency department of a tertiary hospital in Singapore. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820960175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: The emergency department receives a whole breadth of patient types. Those who are imminently dying may attend the emergency department in the hours or days leading up to their demise, necessitating the initiation of end-of-life care in the emergency department. Aim: The aim of our study was to describe the characteristics and management of imminently dying patients who had presented to our emergency department to identify opportunities for improvement in the provision of end-of-life care in the emergency department. Methods: A retrospective study involving patients who died in the emergency department within 48 hours of registration presenting between 1 January 2018 and 31 December 2018 was carried out. Results: Out of 59 included patients, 91.5% had pre-existing medical conditions; 25.4% had end-stage organ failure of which renal and cardiac were most common. Only 15.3% had preferred care plans documented and among these, only a minority (33.3%) had undergone formal advance care planning. The most common presenting symptom among patients who died within 48 hours was dyspnoea (44.1%). The most common investigation done was capillary blood glucose (84.7%) and the most common procedure was an intravenous peripheral cannula insertion (84.7%). Antibiotics were given in 30.5% of the patients and fentanyl was administered in 20.3% for symptom control. Conclusion: The majority of patients presenting to the emergency department within hours or days of their demise had pre-existing chronic or terminal conditions but only a few had specified their preferences for end-of-life care. Investigations and procedures that do not affect patient comfort or outcomes should be minimised.
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Affiliation(s)
- Jia Ling Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Hanxing Xu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Verhoef MJ, de Nijs EJM, Ootjers CS, Fiocco M, Fogteloo AJ, Heringhaus C, Marijnen CAM, Horeweg N, der Linden YMV. End-of-Life Trajectories of Patients With Hematological Malignancies and Patients With Advanced Solid Tumors Visiting the Emergency Department: The Need for a Proactive Integrated Care Approach. Am J Hosp Palliat Care 2020; 37:692-700. [PMID: 31867978 PMCID: PMC7361664 DOI: 10.1177/1049909119896533] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: Patients with hematological malignancies (HM) have more unpredictable disease trajectories compared to patients with advanced solid tumors (STs) and miss opportunities for a palliative care approach. They often undergo intensive disease-directed treatments until the end of life with frequent emergency department (ED) visits and in-hospital deaths. Insight into end-of-life trajectories and quality of end-of-life care can support arranging appropriate care according to patients’ wishes. Method: Mortality follow-back study to compare of end-of-life trajectories of HM and ST patients who died <3 months after their ED visit. Five indicators based on Earle et al. for quality of end-of-life care were assessed: intensive anticancer treatment <3 months, ED visits <6 months, in-hospital death, death in the intensive care unit (ICU), and in-hospice death. Results: We included 78 HM patients and 420 ST patients, with a median age of 63 years; 35% had Eastern Cooperative Oncology Group performance status 3-4. At the ED, common symptoms were dyspnea (22%), pain (18%), and fever (11%). After ED visit, 91% of HM patients versus 76% of ST patients were hospitalized (P = .001). Median survival was 17 days (95% confidence interval [CI]: 15-19): 15 days in HM patients (95% CI: 10-20) versus 18 days in ST patients (95% CI: 15-21), P = .028. Compared to ST patients, HM patients more often died in hospital (68% vs 30%, P < .0001) and in the ICU or ED (30% vs 3%, P < .0001). Conclusion: Because end-of-life care is more aggressive in HM patients compared to ST patients, a proactive integrated care approach with early start of palliative care alongside curative care is warranted. Timely discussions with patients and family about advance care planning and end-of-life choices can avoid inappropriate care at the end of life.
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Affiliation(s)
- Mary-Joanne Verhoef
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellen J M de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Claudia S Ootjers
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Fiocco
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Mathematical Institute, Leiden University, Leiden, the Netherlands
| | - Anne J Fogteloo
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Christian Heringhaus
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Yvette M van der Linden
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
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Dundin A, Siegert C, Miller D, Ouchi K, Lakin JR, Bernacki R, Sciacca K. A Pivot to Palliative: An Interdisciplinary Program Development in Preparation for a Coronavirus Patient Surge in the Emergency Department. J Emerg Nurs 2020; 46:760-767.e1. [PMID: 33023790 PMCID: PMC7442908 DOI: 10.1016/j.jen.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/21/2022]
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Yang C, Yang TT, Tsou YJ, Lin MH, Fan JS, Huang HH, Tsai MC, Yen DHT. Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit. J Chin Med Assoc 2020; 83:500-506. [PMID: 32168079 DOI: 10.1097/jcma.0000000000000297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU). METHODS We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization. RESULTS A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05). CONCLUSION Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.
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Affiliation(s)
- Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tsu-Te Yang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yu-Ju Tsou
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Hui Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ming-Che Tsai
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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George N, Bowman J, Aaronson E, Ouchi K. Past, present, and future of palliative care in emergency medicine in the USA. Acute Med Surg 2020; 7:e497. [PMID: 32395248 PMCID: PMC7204801 DOI: 10.1002/ams2.497] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/12/2020] [Indexed: 01/15/2023] Open
Abstract
The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill‐equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM–palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high‐quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.
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Affiliation(s)
- Naomi George
- University of New Mexico Albuquerque New Mexico.,Division of Critical Care Brigham and Women's Hospital Boston Massachusetts
| | - Jason Bowman
- Division of Critical Care Brigham and Women's Hospital Boston Massachusetts.,Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts
| | - Emily Aaronson
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts
| | - Kei Ouchi
- Division of Critical Care Brigham and Women's Hospital Boston Massachusetts.,Department of Palliative Care and Psychosocial Oncology Dana Farber Cancer Institute Boston Massachusetts
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Chan CWH, Chow MCM, Chan S, Sanson-Fisher R, Waller A, Lai TTK, Kwan CWM. Nurses' perceptions of and barriers to the optimal end-of-life care in hospitals: A cross-sectional study. J Clin Nurs 2020; 29:1209-1219. [PMID: 31889355 DOI: 10.1111/jocn.15160] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/04/2019] [Accepted: 12/20/2019] [Indexed: 12/25/2022]
Abstract
AIMS AND OBJECTIVES To assess nurses' perceptions of what constitutes optimal end-of-life (EOL) care in hospital and evaluate nurses' perceived barriers to EOL care delivery. BACKGROUND Care of dying patients is common in hospitals. However, little is known about the important elements of and barriers to optimal EOL care from key service providers' perspective, which is crucial for quality EOL care in hospital settings. METHOD This is a cross-sectional survey. Nurses practising in hospitals recruited by convenience sampling completed self-report survey questionnaires. STROBE checklist was used in study reporting. RESULTS One hundred and-seventy-five nurses participated in the survey. The majority (70%) had experience in caring for dying patients. The five most highly perceived factors constituting optimal EOL care included the following: "families know and follow patient's EOL wishes"; "patients emotional concerns identified and managed well"; "patients participating in decision-making"; "EOL care documents stored well and easily accessed"; and "provide private rooms and unlimited visiting hours for families of dying patients". Top five barriers were "doctors are too busy"; "nurses are too busy"; "insufficient private room/space"; "nurses have limited training in EOL care"; and "families have unrealistic expectations of patient's prognosis." Multivariate regression analysis identified that nurses without experience in caring for dying patients reported a significantly higher number of perceived barriers towards EOL care (p = .012). Those with postgraduate degree training reported significantly fewer perceived barriers (p = .007). CONCLUSION Findings identified essential elements for optimal hospital EOL care not only involving patients and families in EOL decision and care, but also documentation and environmental issues in the healthcare system level and the needs for strengthening manpower and expertise at palliative care policy level. RELEVANCE TO CLINICAL PRACTICE This study revealed quantitative data to inform health service managers and policy makers in terms of training and service development/ re-design for EOL care in hospital settings.
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Affiliation(s)
- Carmen W H Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Sally Chan
- The University of Newcastle, Newcastle, NSW, Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Theresa T K Lai
- Society for the Promotion of Hospice Care, Jockey Club Home for Hospice, Hong Kong SAR, China
| | - Cecilia W M Kwan
- Bradbury Hospice, New Territories East Cluster, Hospital Authority, Hong Kong SAR, China
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39
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Where do goals of care conversations belong? A case for the emergency department. CAN J EMERG MED 2019; 21:698-700. [DOI: 10.1017/cem.2019.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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40
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Vasquez D, Deland L, Spears K, Metcalfe L, Frost S, Christensen M. Time is Precious: person-centred end of life care in an emergency department. A quality improvement project. Emerg Nurse 2019; 27:33-42. [PMID: 31468850 DOI: 10.7748/en.2019.e1961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 04/29/2023]
Abstract
Supporting and managing end of life in emergency departments (EDs) is often difficult and is becoming increasingly commonplace. Patients who present at the end of life are often triaged as low priority as their signs and symptoms are not considered life-threatening and they are often exposed to unnecessary and inappropriate tests and investigations. This results in increased stress and distress for patients and their family and carers in an environment that is not suited to this type of care. There are few specified palliative care pathways that provide the level of care required by these patients. This article describes the Time is Precious (TiP) project, the development of a palliative care decision-making framework to support and address the needs of patients who present to an ED at end of life, in a timely and appropriate manner. It also reports findings of an evaluation of TiP that show patients are identified more quickly and cared for more appropriately as nursing and medical care can be tailored to meet their needs.
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Affiliation(s)
- Daniela Vasquez
- Bankstown-Lidcombe Hospital, Bankstown, New South Wales (NSW), Australia
| | | | | | - Lauren Metcalfe
- Western Sydney University Campbelltown Campus, Campbelltown NSW, Australia
| | - Steve Frost
- Centre for Applied Nursing Research, Western Sydney University, Sydney NSW, Australia
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The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department. Ann Emerg Med 2019; 75:171-180. [PMID: 31248675 DOI: 10.1016/j.annemergmed.2019.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
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42
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Hanning J, Walker KJ, Horrigan D, Levinson M, Mills A. Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review. Emerg Med Australas 2019; 31:525-532. [DOI: 10.1111/1742-6723.13303] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/26/2019] [Accepted: 03/31/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer Hanning
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Melbourne Medical SchoolThe University of Melbourne Melbourne Victoria Australia
| | - Katherine J Walker
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | | | | | - Amber Mills
- Monash University Melbourne Victoria Australia
- Cabrini Institute Melbourne Victoria Australia
- Bolton Clarke Research Institute Melbourne Victoria Australia
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43
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Koh MY, Lee JF, Montalban S, Foo CL, Hum AY. ED-PALS: A Comprehensive Palliative Care Service for Oncology Patients in the Emergency Department. Am J Hosp Palliat Care 2019; 36:571-576. [DOI: 10.1177/1049909119825847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Mervyn Y.H. Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
| | - Jia F. Lee
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Socrates Montalban
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chik L. Foo
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Y.M. Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
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44
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Missed Opportunities: Integrating Palliative Care into the Emergency Department for Older Adults Presenting as Level I Triage Priority from Long-Term Care Facilities. J Emerg Med 2018; 56:145-152. [PMID: 30527561 DOI: 10.1016/j.jemermed.2018.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/29/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care. OBJECTIVE Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement. METHODS We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed. RESULTS Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%). CONCLUSIONS Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED.
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45
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Cooper E, Hutchinson A, Sheikh Z, Taylor P, Townend W, Johnson MJ. Palliative care in the emergency department: A systematic literature qualitative review and thematic synthesis. Palliat Med 2018; 32:1443-1454. [PMID: 30028242 DOI: 10.1177/0269216318783920] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Despite a fast-paced environment, the emergency clinician has a duty to meet the palliative patient's needs. Despite suggested models and interventions, this remains challenging in practice. AIM To raise awareness of these challenges by exploring the experience of palliative care patients and their families and informal carers attending the emergency department, and of the clinicians caring for them. DESIGN Qualitative systematic literature review and thematic synthesis. Search terms related to the population (palliative care patients, family carers, clinicians), exposure (the emergency department) and outcome (experience). The search was international but restricted to English and used a qualitative filter. Title, abstracts and, where retrieved, full texts were reviewed independently by two reviewers against predefined inclusion criteria arbitrated by a third reviewer. Studies were appraised for quality but not excluded on that basis. DATA SOURCES MEDLINE [1946-], Embase[1947-], CINAHL [1981-] and PsycINFO [1987-] with a bibliography search. RESULTS 19 papers of 16 studies were included from Australia ( n = 5), the United Kingdom ( n = 5), and United States ( n = 9) representing 482 clinical staff involved in the emergency department (doctors, nurses, paramedics, social workers, technicians), 61 patients and 36 carers. Nine descriptive themes formed three analytic themes: 'Environment and Purpose', 'Systems of Care and Interdisciplinary Working' and 'Education and Training'. CONCLUSION In the included studies, provision of emergency palliative care is a necessary purpose of the emergency department. Failure to recognise this, gain the necessary skills or change to systems better suited to its delivery perpetuates poor implementation of palliative care in this environment.
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Affiliation(s)
- Esther Cooper
- 1 Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, Mersey Deanery, Health Education England, UK.,2 Hull York Medical School, University of Hull, Hull, UK
| | - Ann Hutchinson
- 3 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Zain Sheikh
- 4 Head and Neck Specialities, York Hospital, York Teaching Hospitals NHS Foundation Trust, York, UK.,5 Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Paul Taylor
- 6 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK.,7 St Luke's Hospice, Sheffield, UK
| | - Will Townend
- 8 Department of Emergency Medicine, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Miriam J Johnson
- 3 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Ducharme J. Acute Pain Management in the Year 2018-A Review. J Acute Med 2018; 8:53-59. [PMID: 32995204 PMCID: PMC7517976 DOI: 10.6705/j.jacme.201806_8(2).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/06/2018] [Accepted: 02/21/2018] [Indexed: 06/11/2023]
Abstract
This review article provides an overview of acute pain management. It highlights the need to provide balanced pain care while limiting harm from opioids as per the World Health Organization (WHO) recommendations for balanced pain care. Opiophobia and its impact on the use of opioids for acute severe pain are discussed. Interventions that can improve global pain care and the role of pain scales in the management of acute pain are discussed. Newer trends in acute pain management in the emergency department (ED) are also reviewed and include: low dose ketamine, intravenous lidocaine, ultra-sound guided regional anesthesia, intravenous paracetamol, and patient controlled analgesia.
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Affiliation(s)
- James Ducharme
- McMaster University Division of Emergency Medicine, Department of Medicine Hamilton Canada
- Humber River Hospital Toronto Canada
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47
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Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents. CAN J EMERG MED 2018; 21:211-218. [DOI: 10.1017/cem.2018.371] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractObjectiveFew studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.MethodsA team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.ResultsSurveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).ConclusionsImportant barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.
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Shoenberger J, Lamba S, Goett R, DeSandre P, Aberger K, Bigelow S, Brandtman T, Chan GK, Zalenski R, Wang D, Rosenberg M, Jubanyik K. Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework. AEM EDUCATION AND TRAINING 2018; 2:130-145. [PMID: 30051080 PMCID: PMC6001832 DOI: 10.1002/aet2.10088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM. METHODS The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine. RESULTS The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators. CONCLUSIONS Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.
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Affiliation(s)
- Jan Shoenberger
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCA
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Spiritual perspectives of emergency medicine doctors and nurses in caring for end-of-life patients: A mixed-method study. Int Emerg Nurs 2018; 37:13-22. [DOI: 10.1016/j.ienj.2017.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 11/20/2022]
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Palliative Care Symptom Management in The Emergency Department: The ABC's of Symptom Management for The Emergency Physician. J Emerg Med 2018; 54:25-32. [DOI: 10.1016/j.jemermed.2017.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/17/2017] [Accepted: 08/02/2017] [Indexed: 11/23/2022]
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