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Harhara T, Buhumaid R, Oyoun Alsoud L, Ibrahim H. Palliative care education: a nationwide qualitative study of emergency medicine residency program directors in the United Arab Emirates. Int J Emerg Med 2024; 17:69. [PMID: 38783214 PMCID: PMC11119274 DOI: 10.1186/s12245-024-00643-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Emergency medicine (EM) physicians routinely care for patients with serious life-limiting illnesses. Educating EM residents to have general skills and competencies in palliative medicine is a global priority. The purpose of this study was to describe the current status of palliative and end-of-life education in EM residency programs in the United Arab Emirates (UAE) and to identify barriers and opportunities to inculcating palliative care (PC) instruction into EM training in a non-Western setting. METHODS Using the American College of Emergency Medicine's milestones for Hospice and Palliative Medicine for Emergency Medicine as a question guide, semi-structured interviews were conducted with program directors of all 7 EM residency programs in the UAE from January through July 2023. Qualitative content analysis was conducted to identify recurring themes. RESULTS All program directors agreed that PC knowledge and skills are essential components of training for EM residents but have had variable success in implementing a structured PC curriculum. Six themes emerged, namely the educational curriculum, PC policies and practices, comprehensive PC services, cultural and religious barriers to PC, EM scope of practice, and supporting residents after patient death. CONCLUSION UAE national EM residency curriculum development is evolving with an emphasis on developing a structured PC curriculum. As EM residencies implement policies and programs to improve care for patients and families dealing with serious illness, future studies are needed to assess the impact of these initiatives on patient quality of life and physician well-being.
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Affiliation(s)
- Thana Harhara
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Rasha Buhumaid
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- Department of Emergency Medicine, Rashid Hospital, Dubai Health, Dubai, United Arab Emirates
| | - Leen Oyoun Alsoud
- Department of Medical Sciences, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates
| | - Halah Ibrahim
- Department of Medical Sciences, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates.
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Sweeny AL, Alsaba N, Grealish L, Denny K, Lukin B, Broadbent A, Huang YL, Ranse J, Ranse K, May K, Crilly J. The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand. Age Ageing 2024; 53:afae067. [PMID: 38594928 PMCID: PMC11004355 DOI: 10.1093/ageing/afae067] [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: 07/24/2023] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people. OBJECTIVES To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere. METHODS We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression. RESULTS From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation. CONCLUSIONS Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.
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Affiliation(s)
- Amy L Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 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
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 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 & Midwifery Education & Research Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Kerina Denny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Department of Intensive Care Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Bill Lukin
- Faculty of Health and Behavioural Sciences, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, 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
| | - Ya-Ling Huang
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health (Nursing), Southern Cross University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 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
| | - Kristen Ranse
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Katya May
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, 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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Bigelow S, Medzon R, Siegel M, Jin R. Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions. J Palliat Care 2024; 39:3-12. [PMID: 36594209 DOI: 10.1177/08258597221149402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: This study aims to evaluate the potential impact of addressing goals-of-care (GOC) with selected patients in the emergency department (ED), GOC documentation, hospital utilization, and patient satisfaction. Method: This is a single-center, retrospective, and prospective, observational convenience-sample study. ED registered nurses (ED RNs) received standardized GOC conversation training. Their selection criteria included a selection interview, a minimum of 3 years of ED clinical experience, and current employment in the ED. ED RNs used a standardized GOC questionnaire. Patient inclusion criteria included age ≥18 years and one or more of the following: chronic kidney disease ≥ stage III, congestive heart failure with an ejection fraction ≤ 40%, chronic obstructive pulmonary disease with home oxygen use, and/or malignancy with metastasis. GOC conversations were recorded in the electronic medical record (EMR). Physician Orders for Life-Sustaining Treatment (POLST) forms were completed as appropriate. Select individual patient data for the 12 months prior to the conversation were compared with the following 12 months. Results: Over 6 months, 94 of 133 patients who were approached consented to the GOC discussion with the RN. All 94 enrolled patients had their GOC recorded into the EMR. One-third already had a completed POLST form prior to ED arrival. 50% without a POLST on ED arrival left with a completed POLST. Eighty-four patients survived the index visit and 46 patients survived to study completion. Patient satisfaction with the interaction was high: In the cohort who survived past the index visit, 95% rated their experience at 4/5 or 5/5 (Likert scale, 5: strongly agree, 1: strongly disagree). In the survival-to-study completion cohort, 100% rated their experience as 4/5 or 5/5. Subsequent median ED visits decreased by 15% (1.0-4.0 interquartile range). There were no statistically significant changes in hospitalizations (both decreased by 25%, 0-3.0) or intensive care unit admissions (0%, 0-0). Conclusions: An ED RN-led GOC conversation had high patient satisfaction and 100% GOC documentation in the EMR. There was a significant increase in ED POLST form completion. There were no significant changes noted in subsequent hospitalizations, length of hospitalization, or intensive care unit utilization.
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Affiliation(s)
- Suzanne Bigelow
- Emergency Medicine, Providence Regional Medical Center Everett, Everett, WA, USA
- Elson School of Medicine, Washington State University, Spokane, WA, USA
| | - Ron Medzon
- Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Solomont Center for Clinical Simulation and Nursing Education, Boston Medical Center, Boston, Massachusetts, USA
| | - Mari Siegel
- Department of Emergency Medicine, Palliative Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Ruyun Jin
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence Research Network, Portland, OR, USA
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Pitzer S, Kutschar P, Paal P, Mülleder P, Lorenzl S, Wosko P, Osterbrink J, Bükki J. Barriers for Adult Patients to Access Palliative Care in Hospitals: A Mixed Methods Systematic Review. J Pain Symptom Manage 2024; 67:e16-e33. [PMID: 37717708 DOI: 10.1016/j.jpainsymman.2023.09.012] [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: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs. AIM To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients. DESIGN A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477). DATA SOURCES The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed. RESULTS After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication. CONCLUSION Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence.
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Affiliation(s)
- Stefan Pitzer
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria.
| | - Patrick Kutschar
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Piret Paal
- Institute of Palliative Care (P.P., S.L.), Paracelsus Medical University, Salzburg, Austria
| | - Patrick Mülleder
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Stefan Lorenzl
- Institute of Palliative Care (P.P., S.L.), Paracelsus Medical University, Salzburg, Austria
| | - Paulina Wosko
- Gesundheit Österreich GmbH (GÖG, Austrian Public Health Institute) (P.W.), Vienna, Austria
| | - Jürgen Osterbrink
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria
| | - Johannes Bükki
- Institute of Nursing Science and Practice (S.P., P.K., P.M., J.O., J.B.), Paracelsus Medical University, Salzburg, Austria; Helios-Kliniken Schwerin (J.B.), Center for Palliative Medicine, Schwerin, Germany
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5
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Um YW, Jo YH, Kim HE, Kang SH, Han DK, Lee JH, Park I. The Prognostic Value of the Modified Surprise Question in Critically Ill Emergency Department Patients. J Palliat Care 2023:8258597231217947. [PMID: 38031344 DOI: 10.1177/08258597231217947] [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: 12/01/2023]
Abstract
Objective: The initiation of palliative care (PC) in the emergency department (ED) is effective in improving the quality of life for seriously ill patients. This study aimed to evaluate the prognostic value of the modified surprise question (mSQ), "Would you be surprised if this patient died in the next 30 days?" as a trigger for initiating PC in critically ill ED patients. Methods: We conducted a prospective cohort study over a 6-month period in an ED, during which 22 emergency residents answered the mSQ for critically ill ED patients (Korean Triage and Acuity Scale 1 or 2). The primary outcome was the accuracy of the positive mSQ (negative response to the mSQ) in predicting 30-day mortality, and logistic regression analysis was performed to identify the prognostic factors. Results: A total of 300 patients were enrolled, and the positive mSQ group included 118 (39.3%) patients. The 30-day mortality rate of the cohort was 10.0%. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive mSQ were 83.3%, 65.6%, 21.2%, and 97.3%, respectively, with a c-statistic of 0.74 and a positive likelihood ratio of 2.42. In a multivariable analysis controlling for clinically relevant variables, the odds ratio for 30-day mortality of the positive mSQ was 4.76 (95% confidence interval, 1.61-14.09; P = .005). Conclusions: The mSQ may be valuable for identifying critically ill ED patients with an increased risk of 30-day mortality. Therefore, it may be utilized as a trigger for PC consultation in the ED.
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Affiliation(s)
- Young Woo Um
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, South Korea
| | - Hee Eun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Hyun Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Dong Kwan Han
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
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6
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Woodrell CD, Mulholland CN, Goldstein NE, Hutchinson CL, Schiano TD, Hansen L. Clinician Perspectives on Palliative Care for People with Hepatocellular Carcinoma: Facilitators of and Barriers to Referral. Cancers (Basel) 2023; 15:3617. [PMID: 37509278 PMCID: PMC10377573 DOI: 10.3390/cancers15143617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Little is known about facilitators of and barriers to palliative care referral for people with hepatocellular carcinoma (HCC). The objective of this study is to identify facilitators and barriers of palliative care referral described by HCC-treating clinicians. (2) Methods: Semi-structured interviews (n = 16) were conducted with HCC-treating clinicians at two centers, focusing on referral patterns, palliative care needs, and disease course. A code book was created, axial coding was used to code all interviews, and selective coding was used to identify facilitators and barriers of palliative care referral. (3) Results: Facilitators included helpfulness at times of transition; help with management of certain symptoms; provision of psychosocial support; and positive experiences with referral. Barriers included feasibility concerns; lack of information about palliative care and who is appropriate; lack of symptoms requiring outside referral; and concerns that palliative care conveys loss of hope. (4) Conclusions: Participants noted the helpfulness of palliative care at specific points in the disease trajectory and cited barriers related to feasibility, lack of need, lack of awareness, and loss of hope. The results show actionable issues that can be addressed in future research to leverage the benefits of and overcome the barriers to palliative care for people with HCC.
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Affiliation(s)
- Christopher D Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY 10468, USA
| | - Christie N Mulholland
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Carole L Hutchinson
- Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Thomas D Schiano
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Recanati/Miller Transplantation Institute, Division of Liver Diseases, New York, NY 10029, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Sciences University, Portland, OR 97239, USA
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7
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Erel M, Marcus EL, DeKeyser Ganz F. Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings. Front Med (Lausanne) 2023; 10:1145142. [PMID: 37425320 PMCID: PMC10325688 DOI: 10.3389/fmed.2023.1145142] [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: 01/15/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD. Methods Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases. Results The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia. Conclusion Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.
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Affiliation(s)
- Meira Erel
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Jerusalem, Israel
| | | | - Freda DeKeyser Ganz
- Henrietta Szold Hadassah-Hebrew University School of Nursing, Jerusalem, Israel
- Faculty of Health and Life Sciences, Jerusalem College of Technology, Jerusalem, Israel
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8
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Aaronson EL, Kennedy M, Gillis-Crouch G, Zheng H, Jacobsen J, Ouchi K, Jackson V, Ritchie CS, Gioiella ME, Greenwald JL. Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values. J Palliat Med 2023; 26:517-526. [PMID: 36576866 PMCID: PMC10325815 DOI: 10.1089/jpm.2022.0136] [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] [Accepted: 09/21/2022] [Indexed: 12/29/2022] Open
Abstract
Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Gillis-Crouch
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Zheng
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Seel Ritchie
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marie Elena Gioiella
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey L. Greenwald
- Department of Internal Medicine Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Tiah L, Chua MT, Kuan WS, Tan A, Tay E, Yash Pal R, Dong C. Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis. Medicina (B Aires) 2023; 59:medicina59030456. [PMID: 36984457 PMCID: PMC10053832 DOI: 10.3390/medicina59030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
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Affiliation(s)
- Ling Tiah
- Accident & Emergency Department, Changi General Hospital, Singapore Health Services, Singapore 529889, Singapore
- Correspondence:
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Alina Tan
- Department of Anesthesia, National University Hospital, National University of Singapore, Singapore 119074, Singapore
| | - Eileen Tay
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Chaoyan Dong
- Education Office, Sengkang General Hospital, Singapore Health Services, Singapore 554886, Singapore
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10
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Bowman JK, Aaronson EL, Petrillo LA, Jacobsen JC. Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID. J Palliat Med 2022; 26:662-666. [PMID: 36378862 DOI: 10.1089/jpm.2022.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.
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Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine and Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura A. Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet C. Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Lund University Institute for Palliative Care, Lund, Sweden
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11
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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 PMCID: PMC11298868 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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12
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Rege RM, Peyton K, Pajka SE, Grudzen CR, Conroy MJ, Southerland LT. Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study. J Pain Symptom Manage 2022; 63:e281-e286. [PMID: 34411660 PMCID: PMC9069289 DOI: 10.1016/j.jpainsymman.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice. METHODS Setting: Academic ED with 82,000 annual visits. POPULATION ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition. RESULTS Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27). CONCLUSION Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.
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Affiliation(s)
- Rahul M Rege
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH.
| | - Kelee Peyton
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Sarah E Pajka
- The Ohio State University College of Medicine, (S.E.P.) Columbus OH
| | - Corita R Grudzen
- Department of Population Health, (C.R.G.) NYU Grossman School of Medicine, New York, NY
| | - Mark J Conroy
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
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13
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Webster KD, Webster S, Rhodes SM. Registration Attendants Show Poor Readiness to Handle Advanced Care Planning Discussions. Palliat Med Rep 2021; 2:340-348. [PMID: 34927161 PMCID: PMC8675096 DOI: 10.1089/pmr.2021.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Emergency departments (ED) and other medical points of care are required to provide patients with advance directive (AD) information. Although many hospitals provide AD information in EDs, the comfort and preparation of the ED staff with this responsibility is unclear. Objective: To determine the attitudes, comfort levels, and prior training of ED staff with AD. Methods: The ED social workers, nurses, registration attendants, residents, and attending physicians at two academic hospitals completed a survey about their attitudes around, preparedness for, and experiences with advance care planning (ACP) discussions in the ED. Results: We received responses from 220 ED staff. Preparedness to discuss ACP with patients varied by profession. Eighty percent of social workers (n = 4/5) and 52% (n = 16/31) of attending physicians reported preparedness to handle ACP discussions. Registration attendants were the least prepared, and only 4% (n = 1/24) reported preparedness to discuss ACP. Attempts at ACP discussions with patients also differed by profession, with attending physicians being the most likely (77%, n = 24/31), whereas registration attendants were the least likely (8%, n = 2/24). Fifty-nine percent of surveyed staff (n = 130/220) believed that ACP was a component of emergency care, although only 13% (n = 29/220) had received training. Conclusion: The ED staff are in favor of ACP in the ED. Preparedness for, and attempts of ACP discussions with patients in the ED vary by profession. Attending physicians and social workers tend to be the most prepared, and they report the most frequent attempts at discussions with patients. Despite the fact that registration attendants are frequently tasked with asking about patient ADs, they show little confidence in asking about and discussing such matters. Our research indicates that registration attendants feel unprepared to guide discussions of ADs and should not do so without additional training.
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Affiliation(s)
- Kevin D Webster
- Diné College, School of Science, Technology, Engineering and Math, Tsaile, Arizona, USA.,Planetary Science Institute, Tucson, Arizona, USA
| | - Sabrina Webster
- Family Medicne Resident Physician, Aurora Health Care, Milwaukee, Wisconsin, USA
| | - Suzanne Michelle Rhodes
- Palliative and Emergency Medicine Physician, Flagstaff Medical Center, Flagstaff, Arizona, USA
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14
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Walker LE, Bellolio MF, Dobler CC, Hargraves IG, Pignolo RJ, Shaw K, Strand JJ, Thorsteinsdottir B, Wilson ME, Hess EP. Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting. MDM Policy Pract 2021; 6:23814683211058082. [PMID: 34796267 PMCID: PMC8593304 DOI: 10.1177/23814683211058082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 10/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work. Design A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these. Results A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary. Limitations Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis. Conclusions Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.
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Affiliation(s)
| | | | - Claudia C Dobler
- Mayo Clinic, Rochester, Minnesota; Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | | | | | | | - Jacob J Strand
- Department of General Internal Medicine Center for Palliative Medicine
| | | | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Wright R, Lowton K, Hansen BR, Grocott P. Older adult and family caregiver preferences for emergency department based-palliative care: An experience-based co-design study. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2020.100016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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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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17
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Russell E, Hall AK, McKaigney C, Goldie C, Harle I, Sivilotti MLA. Code Status Documentation Availability and Accuracy Among Emergency Patients with End-stage Disease. West J Emerg Med 2021; 22:628-635. [PMID: 34125038 PMCID: PMC8203022 DOI: 10.5811/westjem.2020.12.46801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/24/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Some patients with end-stage disease who may neither want nor benefit from aggressive resuscitation receive such treatment if they cannot communicate in an emergency. Timely access to patients' current resuscitation wishes, or "code status," should be a key metric of electronic health records (EHR). We sought to determine what percentage of a cohort of patients with end-stage disease who present to the emergency department (ED) have accessible, code status documents, and for those who do, how quickly can this documentation be retrieved. METHODS In this cross-sectional study of ED patients with end-stage disease (eg, palliative care, metastatic malignancy, home oxygen, dialysis) conducted during purposefully sampled random accrual times we performed a standardized, timed review of available health records, including accompanying transfer documents. We also interviewed consenting patients and substitute decision makers to compare available code status documents to their current wishes. RESULTS Code status documentation was unavailable within 15 minutes of ED arrival in most cases (54/85, or 63%). Retrieval time was under five minutes in the rest, especially when "one click deep" in the EHR. When interviewed, 20/32 (63%) expressed "do not resuscitate" wishes, 10 of whom had no supporting documentation. Patients from assisted-living (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.7-26) and long-term care facilities (OR 13; 95% CI, 2.5-65) were more likely to have a documented code status available compared to those living in the community. CONCLUSION The majority of patients with end-stage disease, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have code status documents readily available upon arrival to our tertiary care ED. Patients living in the community with advanced disease may be at higher risk for unwanted resuscitative efforts should they present to hospital in extremis. While easily retrievable code status documentation within the EHR shows promise, its accuracy and validity remain important considerations.
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Affiliation(s)
- Evan Russell
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada
| | - Andrew K Hall
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada
| | - Conor McKaigney
- University of Calgary, Department of Emergency Medicine, Calgary, Alberta, Canada
| | - Craig Goldie
- Queen's University, Department of Medicine, Division of Palliative Care, Kingston, Ontario, Canada
| | - Ingrid Harle
- Queen's University, Department of Medicine, Division of Palliative Care, Kingston, Ontario, Canada
| | - Marco L A Sivilotti
- Queen's University, Department of Emergency Medicine, Kingston, Ontario, Canada.,Queen's University, Department of Biomedical & Molecular Sciences, Kingston, Ontario, Canada
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18
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Wong KH, Yang LCM, Woo KWR, Wong OF, Kwong WY, Tse CF, Lam SKT, Ma HM, Lit CHA, Ho HF, Shih YN. Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study. BMC Palliat Care 2021; 20:48. [PMID: 33757502 PMCID: PMC7988912 DOI: 10.1186/s12904-021-00742-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 03/15/2021] [Indexed: 11/26/2022] Open
Abstract
Background Due to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas. Methods A questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services. Results In total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics. Conclusions The study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00742-1.
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Affiliation(s)
- Kwun Hang Wong
- Accident and Emergency Department, North Lantau Hospital, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - Li Chuan Marc Yang
- Fong Tam Yuen Leung Emergency Medicine Centre, The Chinese University of Hong Kong Medical Centre, 9 Chak Cheung Street, Shatin, New Territories, Hong Kong. .,Accident and Emergency Department, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong.
| | - Kam Wing Raymond Woo
- Department of Medicine and Geriatrics, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Kowloon, Hong Kong
| | - Oi Fung Wong
- Accident and Emergency Department, North Lantau Hospital, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - Wing Yan Kwong
- Accident and Emergency Department, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong
| | - Choi Fung Tse
- Accident and Emergency Department, Tin Shui Wai Hospital, 11 Tin Tan Street, Tin Shui Wai, New Territories, Hong Kong
| | - Shing Kit Tommy Lam
- Accident and Emergency Department, Poh Oi Hospital, Au Tau, Yuen Long, New Territories, Hong Kong
| | - Hing Man Ma
- Accident and Emergency Department, North Lantau Hospital, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - Chau Hung Albert Lit
- Accident and Emergency Department, North Lantau Hospital, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - Hiu Fai Ho
- Accident and Emergency Department, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong
| | - Yau Ngai Shih
- Accident and Emergency Department, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Lai Chi Kok, Kowloon, Hong Kong
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Al-Ansari A, Suroor S, AboSerea S, Abd-El-Gawad WM. Harmonising palliative care: a national survey to evaluate the knowledge and attitude of emergency physicians towards palliative care in Kuwait. BMJ Support Palliat Care 2020:bmjspcare-2019-002141. [PMID: 33168669 DOI: 10.1136/bmjspcare-2019-002141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 08/18/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIM Although the challenges of integrating palliative care practices across care settings are real and well recognised, to date little is known about palliative care practices of emergency physicians (EPs) in Kuwait. Therefore, this study aims to explore the attitude and knowledge of EPs in providing palliative care in all general hospitals in Kuwait. METHOD A cross-sectional survey was performed in the emergency rooms of all general hospitals in Kuwait using the Palliative Care Attitude and Knowledge Questionnaire. RESULTS Of the total number of physicians working in emergency rooms (n=156), 104 (66.67%) had completed the survey. 76.9% (n=80) of the EPs had an uncertain attitude towards palliative care. Most of the EPs (n=73, 70.28%) did not discuss the patients' need for palliative care either with the patients or with their families. Only 16 (15.4%) of the EPs responded correctly to most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge. Experience ≥11 years and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position and nationality (OR: 5.747 (CI 1.031 to 25.00), 1.458(CI 1.148 to 1.851); p values: 0.021, 0.002, respectively). CONCLUSIONS Despite recognising palliative care as an important competence, the majority of the EPs in Kuwait had uncertain attitude and poor knowledge towards palliative care. Efforts should be made to enhance physician training and provide palliative care resources to improve the quality of care given to patients visiting emergency departments.
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Affiliation(s)
- Ameena Al-Ansari
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Saleem Suroor
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Sobhi AboSerea
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
| | - Wafaa Mostafa Abd-El-Gawad
- Palliative Care Center, Kuwait Ministry of Health, Al Sabah Medical Area, Kuwait
- Geriatrics and Gerontology Department, Ain Shams University, Cairo, Egypt
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20
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Lai L, Sato R, Ouchi K, Landman AB, Zhang HM. Digital health innovation to integrate palliative care during the COVID-19 pandemic. Am J Emerg Med 2020; 46:664-666. [PMID: 33046309 PMCID: PMC7437574 DOI: 10.1016/j.ajem.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Lucinda Lai
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Affiliated Emergency Medicine Residency Program, 5 Emerson Place, Suite 101, Boston, MA 02114, United States of America
| | - Rintaro Sato
- Brigham Digital Innovation Hub, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Adam B Landman
- Brigham Digital Innovation Hub, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America
| | - Haipeng Mark Zhang
- Brigham Digital Innovation Hub, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States of America; Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, 450 Brookline Avenue, Boston, MA 02115, United States of America.
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Paske JRT, DeWitt S, Hicks R, Semmens S, Vaughan L. Palliative Care and Rapid Emergency Screening Tool and the Palliative Performance Scale to Predict Survival of Older Adults Admitted to the Hospital From the Emergency Department. Am J Hosp Palliat Care 2020; 38:800-806. [PMID: 32990021 DOI: 10.1177/1049909120960713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Palliative Care and Rapid Emergency Screening (P-CaRES) tool has been validated to identify patients in the emergency department (ED) with unmet palliative care needs, but no prognostic data have been published. The Palliative Performance Scale (PPS) has been validated to predict survival based on performance status and separately has been shown to predict survival among adults admitted to the hospital from the ED. OBJECTIVE To concurrently validate the 6-month prognostic utility of P-CaRES with a replication of prior studies that demonstrated the prognostic utility of the PPS among adults admitted to the hospital from the ED. DESIGN Prospective cohort study. SETTING/SUBJECTS Adults >55 years admitted to the hospital from the ED at an urban academic hospital in South Carolina. MEASUREMENT Baseline PPS score and P-CaRES status were evaluated within 51 hours of admission. Vital status at 6 months was evaluated by phone or chart review. RESULTS 131 of 145 participants completed the study. Six-month survival was 79.2% of those with a PPS of 60-100 (22/106 died) and 48% of those with a PPS of 10-50 (13/25 died) (p = 0.0004). Six-month survival was 85.2% for P-CaRES negative (13/88 died) and 48.8% for P-CaRES positive (22/43 died) (p < 0.0001). The inferred hazard ratio (HR) for PPS 10-50, as compared to PPS 60-100 was 3.003 (95%CI (1.475, 6.112) p = 0.0024) and the HR for P-CaRES positive, as compared to P-CaRES negative was 4.186 (95%CI (2.052, 8.536) p < 0.0001). CONCLUSION The P-CaRES tool and PPS can predict 6-month survival of older adults admitted from the ED.
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Affiliation(s)
| | - Sarah DeWitt
- 2345Medical University of South Carolina, Charleston, SC, USA.,246010Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Robin Hicks
- 2345Medical University of South Carolina, Charleston, SC, USA.,3740UPMC Pinnacle Health, Harrisburg, PA, USA
| | - Shana Semmens
- 2345Medical University of South Carolina, Charleston, SC, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Leigh Vaughan
- 2345Medical University of South Carolina, Charleston, SC, USA
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Andersen SK, Montgomery CL, Bagshaw SM. Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission. J Crit Care 2020; 60:279-284. [PMID: 32942163 DOI: 10.1016/j.jcrc.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe patients who die within 24 h of ICU admission in order to better optimize care delivery. METHODS This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression. RESULTS Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6). CONCLUSION Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.
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Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
| | - Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada; Alberta Health Services Critical Care Strategic Clinical Network, Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
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23
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Vogel R, McGraw C, Redmond D, Bourg Retired P, Dreiman C, Tanner A, Lynch N, Bar-Or D. The ACS-TQIP palliative care guidelines at two level I trauma centres: a prospective study of patient and caregiver satisfaction. BMJ Support Palliat Care 2020; 12:e120-e128. [PMID: 32581006 DOI: 10.1136/bmjspcare-2020-002229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To measure trauma patient and caregiver satisfaction before and after implementation of standardised palliative care (PC) guidelines. METHODS Prospective pre-post study at two level-I trauma centres. PC satisfaction surveys were administered prior to discharge for consented trauma patients (Family Satisfaction with Advanced Cancer Scale, Patient (FAMCARE-P13) survey)≥55 years, and their caregivers (FAMCARE survey), from 1 November 2016 to 30 November 2018. Standardised PC guidelines were implemented January 2018 and included consultations, prognostication assessments, identification of proxies, review of advanced directives and do not resuscitate orders within 24 hours of admission, while advanced goals of care, formal family meetings and spiritual care support were recommended within 72 hours of admission. Generalised linear models were used to determine whether differences in patient or caregiver satisfaction existed pre versus post implementation. RESULTS There were 572 patients (299 pre; 273 post) and 595 caregivers (334 pre; 261 post) included. Overall patient satisfaction significantly increased post implementation (82.0 vs 86.0, p=0.001). After adjustment, the implementation of the guidelines was an independent predictor of higher overall patient satisfaction (least squares mean (LSM= (83.8% (95%CI 81.2%-86.5%) vs 80.3% (77.7%-82.9%), p=0.003)). Compared with preimplementation, patient satisfaction was significantly higher post implementation in the following domains: information giving (80.9 vs 85.5, p=0.001), followed by physical care (82.2 vs 86.0, p=0.002), availability of care (83.4 vs 86.8, p=0.007) and psychosocial care (84.7 vs 87.6, p=0.04). No significant differences in caregiver satisfaction were found before or after adjustment (LSMpre: 83.1% (95%CI 80.9%-85.3%) vs. post: 82.4% (80.3%-84.5%), p=0.56)) CONCLUSIONS: Our data suggest that the implementation of PC guidelines significantly improved patient satisfaction following traumatic injury, while maintaining robust caregiver satisfaction.
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Affiliation(s)
- Rebecca Vogel
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Constance McGraw
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA.,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Diane Redmond
- Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Pamela Bourg Retired
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Chester Dreiman
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Allen Tanner
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Neal Lynch
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA .,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
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Di Leo S, Alquati S, Autelitano C, Costantini M, Martucci G, De Vincenzo F, Kuczynska B, Morini A, Trabucco L, Ursicelli R, Catania G, Ghirotto L. Palliative care in the emergency department as seen by providers and users: a qualitative study. Scand J Trauma Resusc Emerg Med 2019; 27:88. [PMID: 31533807 PMCID: PMC6751856 DOI: 10.1186/s13049-019-0662-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals’ and users’ perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments. Methods A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis. Results Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care. Conclusions This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.
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Affiliation(s)
- Silvia Di Leo
- Psycho-oncology Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Sara Alquati
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cristina Autelitano
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gianfranco Martucci
- Palliative Care Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Beata Kuczynska
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Morini
- Day Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Laura Trabucco
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Raffaella Ursicelli
- Department of Emergency Medicine, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gianluca Catania
- Department of Health Sciences, University of Genoa, Genova, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
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25
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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26
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Bell D, Ruttenberg MB, Chai E. Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department. Clin Geriatr Med 2019; 34:453-467. [PMID: 30031427 DOI: 10.1016/j.cger.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.
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Affiliation(s)
- Daniel Bell
- Department of Emergency Medicine, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
| | - Margaret Brungraber Ruttenberg
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Emily Chai
- Geriatrics and Palliative Medicine Inpatient Services, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1970, New York, NY 10029, USA
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27
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Supportive Care Nursing Clinical Protocol Incorporates Holism in a Public Acute Care Hospital. Holist Nurs Pract 2018; 32:182-188. [DOI: 10.1097/hnp.0000000000000274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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28
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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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Kim K, Chakravarthy B, Anderson C, Liao S. To Intubate or Not to Intubate: Emergency Medicine Physicians' Perspective on Intubating Critically Ill, Terminal Cancer Patients. J Pain Symptom Manage 2017; 54:654-660.e1. [PMID: 28754440 DOI: 10.1016/j.jpainsymman.2017.07.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/15/2017] [Accepted: 07/18/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT Emergency physicians (EPs) often need to make a decision whether or not to intubate a terminal cancer patient. OBJECTIVE The objective of this study was to explore EPs' attitudes about intubating critically ill, terminal cancer patients. METHODS Fifty EPs at three emergency departments (one university based, one community, and one Health Maintenance Organization) in Southern California participated in an anonymous survey that presented a hypothetical case of an end-stage lung cancer patient in pending respiratory failure. Fourteen questions along a five-point Likert scale asked EPs about prognosis and factors that influence their decision to intubate or not. RESULTS A convenience sampling of 50 EPs yielded a 100% survey response rate. Ninety-four percent believed intubation would not provide an overall survival benefit. If the family insisted, 26% would intubate the patient even with a do-not-intubate (DNI) status. Ninety-four percent would postpone intubation if palliative consultation were available in the ED. Sixty-eight percent believed that a discussion about goals of care was more time consuming than intubation. Only 16% believed they had sufficient training in palliative care. Although 29% who felt they had inadequate palliative care training would intubate the patient with a DNI, only 13% of EPs with self-perceived adequate palliative care training would intubate that patient. CONCLUSION EPs vary in their attitudes about intubating dying cancer patients when families demanded it, even when they believed it was nonbeneficial and against the patient's wishes. Palliative care education has the potential to influence that decision making. Intubation could be mitigated by the availability of palliative consultation in the ED.
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Affiliation(s)
- Kenneth Kim
- Department of Palliative Medicine, University of California, Irvine, California, USA.
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Craig Anderson
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Solomon Liao
- Department of Palliative Medicine, University of California, Irvine, California, USA
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Blackwell RWN, Lowton K, Robert G, Grudzen C, Grocott P. Using Experience-based Co-design with older patients, their families and staff to improve palliative care experiences in the Emergency Department: A reflective critique on the process and outcomes. Int J Nurs Stud 2017; 68:83-94. [PMID: 28095347 DOI: 10.1016/j.ijnurstu.2017.01.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Increasing use of emergency departments among older patients with palliative needs has led to the development of several service-level interventions intended to improve care quality. There is little evidence of patient and family involvement in developmental processes, and little is known about the experiences of - and preferences for - palliative care delivery in this setting. Participatory action research seeking to enable collaborative working between patients and staff should enhance the impact of local quality improvement work but has not been widely implemented in such a complex setting. OBJECTIVES To critique the feasibility of this methodology as a quality improvement intervention in complex healthcare settings, laying a foundation for future work. SETTING an Emergency Department in a large teaching hospital in the United Kingdom. METHODS Experience-based Co-design incorporating: 150h of nonparticipant observation; semi-structured interviews with 15 staff members about their experiences of palliative care delivery; 5 focus groups with 64 staff members to explore challenges in delivering palliative care; 10 filmed semi-structured interviews with palliative care patients or their family members; a co-design event involving staff, patients and family members. FINDINGS the study successfully identified quality improvement priorities leading to changes in Emergency Department-palliative care processes. Further outputs were the creation of a patient-family-staff experience training DVD to encourage reflective discussion and the identification and application of generic design principles for improving palliative care in the Emergency Department. There were benefits and challenges associated with using Experience-based Co-design in this setting. Benefits included the flexibility of the approach, the high levels of engagement and responsiveness of patients, families and staff, and the impact of using filmed narrative interviews to enhance the 'voice' of seldom heard patients and families. Challenges included high levels of staff turnover during the 19 month project, significant time constraints in the Emergency Department and the ability of older patients and their families to fully participate in the co-design process. CONCLUSION Experience-based Co-design is a useful approach for encouraging collaborative working between vulnerable patients, family and staff in complex healthcare environments. The flexibility of the approach allows the specific needs of participants to be accounted for, enabling fuller engagement with those who typically may not be invited to contribute to quality improvement work. Recommendations for future studies in this and similar settings include testing the 'accelerated' form of the approach and experimenting with alternative ways of increasing involvement of patients/families in the co-design phase.
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Affiliation(s)
- Rebecca Wright Née Blackwell
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, JCMB, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Karen Lowton
- Department of Sociology, University of Sussex, Freeman Building, Falmer, Brighton, BN1 9RH, UK
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, JCMB, 57 Waterloo Road, London, SE1 8WA, UK
| | - Corita Grudzen
- Ronald O. Perelman Department of Emergency Medicine, Associate Professor of Emergency Medicine and Population Health, NYU School of Medicine, USA
| | - Patricia Grocott
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, JCMB, 57 Waterloo Road, London, SE1 8WA, UK
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George NR, Kryworuchko J, Hunold KM, Ouchi K, Berman A, Wright R, Grudzen CR, Kovalerchik O, LeFebvre EM, Lindor RA, Quest TE, Schmidt TA, Sussman T, Vandenbroucke A, Volandes AE, Platts-Mills TF. Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda. Acad Emerg Med 2016; 23:1394-1402. [PMID: 27611892 DOI: 10.1111/acem.13083] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.
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Affiliation(s)
- Naomi R. George
- Department of Emergency Medicine; Brown University; Providence RI
| | | | | | - Kei Ouchi
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA
| | - Amy Berman
- Hartford Program Officer/Patient Representative; New York NY
| | - Rebecca Wright
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | - Corita R. Grudzen
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | | | - Eric M. LeFebvre
- Department of Emergency Medicine, Geriatric Fellow; University of North Carolina-Chapel Hill; Chapel Hill NC
| | | | - Tammie E. Quest
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Terri A. Schmidt
- Departments of Emergency Medicine and Hematology/Oncology; Oregon Health and Science University; Portland OR
| | - Tamara Sussman
- School of Social Work; McGill University; Montreal Quebec Canada
| | | | | | - Timothy F. Platts-Mills
- Department of Emergency Medicine and Department of Anesthesiology; University of North Carolina-Chapel Hill; Chapel Hill NC
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Revels A, Sabo B, Snelgrove-Clarke E, Price S, Field S, Helwig M. Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol. ACTA ACUST UNITED AC 2016; 14:75-86. [PMID: 27532465 DOI: 10.11124/jbisrir-2016-002647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTIONS/OBJECTIVES The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?
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Affiliation(s)
- Amanda Revels
- 1School of Nursing, Dalhousie University 2Faculty of Medicine, Dalhousie University 3Department of Pediatrics, IWK Health Centre 4Department of Emergency Medicine, Capital District Health Authority 5WK Kellogg Health Sciences Library, Dalhousie University 6Department of Obstetrics & Gynecology, IWK Health Centre, Halifax, Nova Scotia, Canada
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Kraus CK, Greenberg MR, Ray DE, Dy SM. Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors. J Pain Symptom Manage 2016; 51:898-906. [PMID: 26988848 DOI: 10.1016/j.jpainsymman.2015.12.334] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority. OBJECTIVES To assess PC competency education in EM residency programs. METHODS This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training. RESULTS Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues. CONCLUSION There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.
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Affiliation(s)
- Chadd K Kraus
- Department of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
| | - Marna R Greenberg
- Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Daniel E Ray
- Section of Palliative Medicine and Hospice, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sydney Morss Dy
- Duffey Pain/Palliative Care Program, Johns Hopkins Kimmel Cancer Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Elsayem AF, Elzubeir HE, Brock PA, Todd KH. Integrating palliative care in oncologic emergency departments: Challenges and opportunities. World J Clin Oncol 2016; 7:227-33. [PMID: 27081645 PMCID: PMC4826968 DOI: 10.5306/wjco.v7.i2.227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.
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Aldridge MD, Hasselaar J, Garralda E, van der Eerden M, Stevenson D, McKendrick K, Centeno C, Meier DE. Education, implementation, and policy barriers to greater integration of palliative care: A literature review. Palliat Med 2016; 30:224-39. [PMID: 26405109 DOI: 10.1177/0269216315606645] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early integration of palliative care into the management of patients with serious disease has the potential to both improve quality of life of patients and families and reduce healthcare costs. Despite these benefits, significant barriers exist in the United States to the early integration of palliative care in the disease trajectory of individuals with serious illness. AIM To provide an overview of the barriers to more widespread palliative care integration in the United States. DESIGN AND DATA SOURCES A literature review using PubMed from 2005 to March 2015 augmented by primary data collected from 405 hospitals included in the Center to Advance Palliative Care's National Palliative Care Registry for years 2012 and 2013. We use the World Health Organization's Public Health Strategy for Palliative Care as a framework for analyzing barriers to palliative care integration. RESULTS We identified key barriers to palliative care integration across three World Health Organization domains: (1) education domain: lack of adequate education/training and perception of palliative care as end-of-life care; (2) implementation domain: inadequate size of palliative medicine-trained workforce, challenge of identifying patients appropriate for palliative care referral, and need for culture change across settings; (3) policy domain: fragmented healthcare system, need for greater funding for research, lack of adequate reimbursement for palliative care, and regulatory barriers. CONCLUSION We describe the key policy and educational opportunities in the United States to address and potentially overcome the barriers to greater integration of palliative care into the healthcare of Americans with serious illness.
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Affiliation(s)
- Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Eduardo Garralda
- ATLANTES Research Programme, Institute for Culture and Society, University of Navarra, Pamplona, Spain and Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain
| | | | - David Stevenson
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Karen McKendrick
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlos Centeno
- ATLANTES Research Programme, Institute for Culture and Society, University of Navarra, Pamplona, Spain and Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain
| | - Diane E Meier
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Center to Advance Palliative Care, New York, NY, USA
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Szekendi MK, Vaughn J, Lal A, Ouchi K, Williams MV. The Prevalence of Inpatients at 33 U.S. Hospitals Appropriate for and Receiving Referral to Palliative Care. J Palliat Med 2016; 19:360-72. [PMID: 26788621 DOI: 10.1089/jpm.2015.0236] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The extent of unmet need for palliative care in U.S. hospitals remains largely unknown. We conducted a multisite cross-sectional, retrospective point prevalence analysis to determine the size and characteristics of the population of inpatients at 33 U.S. hospitals who were appropriate for palliative care referral, as well as the percentage of these patients who were referred for and/or received palliative care services. We also conducted a qualitative assessment of barriers and facilitators to referral, focusing on organizational characteristics that might influence palliative care referral practices. METHODS Patients appropriate for palliative care referral were defined as adult (≥18 years) patients with any diagnosis of a poor-prognosis cancer, New York Heart Association class IV congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease who had inpatient status in 1 of 33 hospitals on May 13, 2014. Qualitative assessment involved interviews of palliative care team members and nonpalliative care frontline providers. RESULTS Nearly 19% of inpatients on the point prevalence day were deemed appropriate for palliative care referral. Of these, approximately 39% received a palliative care referral or services. Delivery of palliative care services to these patients varied widely among participating hospitals, ranging from approximately 12% to more than 90%. Factors influencing differences in referral practices included nonstandardized perceptions of referral criteria and variation in palliative care service structures. CONCLUSION This study provides useful information to guide providers, administrators, researchers, and policy experts in planning for optimal provision of palliative care services to those in need.
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Affiliation(s)
- Marilyn K Szekendi
- 1 Member Relations and Insights, University HealthSystem Consortium (UHC), Chicago, Illinois
| | - Jocelyn Vaughn
- 1 Member Relations and Insights, University HealthSystem Consortium (UHC), Chicago, Illinois
| | - Ashima Lal
- 2 Department of Palliative Care, Roswell Park Cancer Institute , Buffalo, New York
| | - Kei Ouchi
- 3 Department of Emergency Medicine, Brigham & Women's Hospital , Boston, Massachusetts
| | - Mark V Williams
- 4 Center for Health Services Research, University of Kentucky , Lexington, Kentucky
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Rogers IR, Lukin B. Applying palliative care principles and practice to emergency medicine. Emerg Med Australas 2015; 27:612-615. [DOI: 10.1111/1742-6723.12494] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ian R Rogers
- Department of Emergency Medicine; St John of God Murdoch Hospital; Perth Western Australia Australia
- The University of Notre Dame Australia; Fremantle Western Australia Australia
| | - Bill Lukin
- Department of Emergency Medicine; Royal Brisbane Hospital; Brisbane Queensland Australia,
- University of Queensland; Brisbane Queensland Australia
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George N, Barrett N, McPeake L, Goett R, Anderson K, Baird J. Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs. Acad Emerg Med 2015; 22:823-37. [PMID: 26171710 DOI: 10.1111/acem.12710] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/20/2015] [Accepted: 01/25/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND The emergency department (ED) is increasingly used by patients with life-limiting illness. These patients are frequently admitted to the hospital, where they suffer from poorly controlled symptoms and are often subjected to marginally effective therapies. Palliative care (PC) has emerged as the specialty that cares for patients with advanced illness. PC has been shown to reduce symptoms, improve quality of life, and decrease resource utilization. Unfortunately, most patients who could benefit from PC are never identified. At present, there exists no validated screening tool to identify significant unmet PC needs among ED patients with life-limiting illness. OBJECTIVES The objective was to develop a simple, content-valid screening tool for use by ED providers to identify ED patients with significant PC needs. A positive screen would result in an inpatient PC consultation. METHODS An initial screening tool was developed based on a critical review of the literature. Content validity was determined by a two-round modified Delphi technique using a panel of PC experts. The expert panel reviewed the items of the tool for accuracy and necessity using a Likert scale and provided narrative feedback. Expert's responses were aggregated and analyzed to revise the tool until consensus was achieved. Greater than 80% agreement, as well as meeting Lawshe's critical values, was required to achieve consensus. RESULTS Fifteen experts completed two rounds of surveys to reach consensus on the content validity of the tool. Three screening items were accepted with minimal revisions. The remaining items were revised, condensed, or eliminated. The final tool contains 13 items divided into three steps: 1) presence of a life-limiting illness, 2) unmet PC needs, and 3) hospital admission. The majority of panelists (86%) endorsed adoption of the final screening tool. CONCLUSIONS Use of a modified Delphi technique resulted in the creation of a content-validated screening tool for identification of ED patients with significant unmet PC needs. Further validation testing of the instrument is warranted.
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Affiliation(s)
- Naomi George
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Nina Barrett
- The New York University School of Medicine; New York NY
| | - Laura McPeake
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Rebecca Goett
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | | | - Janette Baird
- The Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
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Delgado-Guay MO, Kim YJ, Shin SH, Chisholm G, Williams J, Allo J, Bruera E. Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care. J Pain Symptom Manage 2015; 49:497-504. [PMID: 25131891 DOI: 10.1016/j.jpainsymman.2014.07.007] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 07/01/2014] [Accepted: 07/06/2014] [Indexed: 12/12/2022]
Abstract
CONTEXT Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable. OBJECTIVES To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs). METHODS We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED. RESULTS Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99). CONCLUSION Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.
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Affiliation(s)
- Marvin Omar Delgado-Guay
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Yu Jung Kim
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Seong Hoon Shin
- Department of Internal Medicine, College of Medicine, Kosin University, Busan, Republic of Korea
| | - Gary Chisholm
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Julio Allo
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Blum T, Schönfeld N. The lung cancer patient, the pneumologist and palliative care: a developing alliance. Eur Respir J 2014; 45:211-26. [DOI: 10.1183/09031936.00072514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Considerable evidence is now available on the value of palliative care for lung cancer patients in all stages and at all times during the course of the disease. However, pneumologists and their institutions seem to be widely in arrears with the implementation of palliative care concepts and the development of integrated structures.This review focuses on the available evidence and experience of various frequently unmet needs of lung cancer patients, especially psychological, social, spiritual and cultural ones. A PubMed search for evidence on these aspects of palliative care as well as on barriers to the implementation, on outcome parameters and effectiveness, and on structure and process quality was performed with a special focus on lung cancer patients.As a consequence, this review particularly draws pneumologists’ attention to improving their skills in communication with the patients, their relatives and among themselves, and to establish team structures with more far-reaching competences and continuity than existing multilateral cooperations and conferences can provide. Ideally, any process of structural and procedural improvement should be accompanied by scientific evaluation and measures for quality optimisation.
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Shearer FM, Rogers IR, Monterosso L, Ross-Adjie G, Rogers JR. Understanding emergency department staff needs and perceptions in the provision of palliative care. Emerg Med Australas 2014; 26:249-55. [PMID: 24713040 DOI: 10.1111/1742-6723.12215] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary aim of the present study was to investigate Australian ED staff perspectives and needs regarding palliative care provision. Secondary aims were to assess staff views about death and dying, and their awareness of common causes of death in Australia, particularly those where a palliative care approach is appropriate. METHODS All medical and nursing staff working in a private ED in Perth, Western Australia, were asked to complete a combined quantitative and qualitative survey. The survey tool uses a combination of Likert-type scales and open-ended questions. Descriptive statistics and intergroup comparisons were made for all quantifiable variables, whereas formal content analysis was used for text responses. RESULTS Surveys were returned by 22 doctors and 44 nurses, with most reporting only working knowledge of palliative care but clinical proficiency in symptom control. Confidence in palliative care provision was lower among nursing than medical staff but educational needs were similar. Cancer diagnoses were consistently overestimated, and dementia and COPD underestimated, as the most common causes of death. Only six of 63 (9.5%) of respondents identified the correct top five causes of death. CONCLUSIONS Our study suggests that although ED staff expressed confidence regarding symptom management in palliative care, they lacked understanding of the patients in whom a palliative approach could be applied and sought further education in areas, such as end-of-life communication and ethical issues. ED specific training and clinical interventions in palliative care provision would seem to be needed and justified.
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Affiliation(s)
- Freya M Shearer
- Emergency Department, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
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Ouchi K, Wu M, Medairos R, Grudzen CR, Balsells H, Marcus D, Whitson M, Ahmad D, Duprey K, Mancherje N, Bloch H, Jaffrey F, Liberman T. Initiating Palliative Care Consults for Advanced Dementia Patients in the Emergency Department. J Palliat Med 2014; 17:346-50. [DOI: 10.1089/jpm.2013.0285] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Mark Wu
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Robert Medairos
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Corita R. Grudzen
- Department of Emergency Medicine and the Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York
| | - Herberth Balsells
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - David Marcus
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Micah Whitson
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Danish Ahmad
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Kael Duprey
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Noel Mancherje
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Helen Bloch
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Fatima Jaffrey
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Tara Liberman
- Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
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Lamba S, DeSandre PL, Todd KH, Bryant EN, Chan GK, Grudzen CR, Weissman DE, Quest TE. Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration. J Emerg Med 2013; 46:264-70. [PMID: 24286714 DOI: 10.1016/j.jemermed.2013.08.087] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 07/16/2013] [Accepted: 08/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. CASE REPORT We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. DISCUSSION We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. CONCLUSION The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Paul L DeSandre
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Knox H Todd
- Department of Emergency Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Eric N Bryant
- The Institute for Palliative Medicine at San Diego Hospice, San Diego, California
| | - Garrett K Chan
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California; Emergency Department Clinical Decision Unit and Palliative Care Service, Stanford Hospital & Clinics, Stanford, California
| | - Corita R Grudzen
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David E Weissman
- Medical College of Wisconsin Palliative Care Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tammie E Quest
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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