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Walzl N, Sammy IA, Taylor PM, Smith JE, Lowe DJ. Systematic review of factors influencing decisions to limit treatment in the emergency department. Emerg Med J 2022; 39:147-156. [PMID: 33658272 DOI: 10.1136/emermed-2019-209398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature. DESIGN Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis. RESULTS 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors). CONCLUSIONS Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.
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Affiliation(s)
- Nathan Walzl
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Ian A Sammy
- Emergency Department, Scarborough General Hospital, Lower Scarborough, Trinidad and Tobago
- Tobago Regional Health Authority, Lower Scarborough, Trinidad and Tobago
| | - Paul M Taylor
- The University of Sheffield School of Health and Related Research, Sheffield, UK
- St Luke's Hospice, Sheffield, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - David J Lowe
- Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
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Douplat M, Fraticelli L, Claustre C, Peiretti A, Serre P, Bischoff M, Jacquin L, Freyssenge J, Schott AM, Tazarourte K, Frugier S, Khoury CEL, Grezard M, Antoine JD, Dumont O, Lhuillier E, Pierro L, Blain S, Prost C, Sen-Brachet P, Khaldi A. Management of decision of withholding and withdrawing life-sustaining treatments in French EDs. Scand J Trauma Resusc Emerg Med 2020; 28:52. [PMID: 32513282 PMCID: PMC7282105 DOI: 10.1186/s13049-020-00744-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature.
Study objective
We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France.
Method
In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process.
Results
There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives.
Conclusion
The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.
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Reignier J, Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T. Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine. Ann Intensive Care 2019; 9:105. [PMID: 31549266 PMCID: PMC6757069 DOI: 10.1186/s13613-019-0579-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
For many patients, notably among elderly nursing home residents, no plans about end-of-life decisions and palliative care are made. Consequently, when these patients experience life-threatening events, decisions to withhold or withdraw life-support raise major challenges for emergency healthcare professionals. Emergency department premises are not designed for providing the psychological and technical components of end-of-life care. The continuous inflow of large numbers of patients leaves little time for detailed assessments, and emergency department staff often lack training in end-of-life issues. For prehospital medical teams (in France, the physician-staffed mobile emergency and intensive care units known as SMURs), implementing treatment withholding and withdrawal decisions that may have been made before the acute event is not the main focus. The challenge lies in circumventing the apparent contradiction between the need to make immediate decisions and the requirement to set up a complex treatment project that may lead to treatment withholding and/or withdrawal. Laws and recommendations are of little assistance for making treatment withholding and withdrawal decisions in the emergency setting. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and French Society of Emergency Medicine (Société Française de Médecine d'Urgence, SFMU) tasked a panel of emergency physicians and intensivists with developing a document to serve both as a position paper on life-support withholding and withdrawal in the emergency setting and as a guide for professionals providing emergency care. The task force based its work on the available legislation and recommendations and on a review of published studies.
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Affiliation(s)
- Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France. .,Université de Nantes, Nantes, France.
| | - Anne-Laure Feral-Pierssens
- Assistance Publique Hôpitaux de Paris, Service des Urgences, Hôpital Européen Georges Pompidou Paris, Paris, France
| | - Thierry Boulain
- Service de Réanimation Médicale Polyvalente, Centre Hospitalier Régional Orléans, Orléans, France
| | - Françoise Carpentier
- Pôle Urgences Médecine Aigüe, Hôpital Universitaire des Alpes, Grenoble, France.,Université de Grenoble, Grenoble, France
| | - Pierrick Le Borgne
- Service d'Accueil des Urgences, Hôpital de Hautepierre, CHRU Strasbourg, Strasbourg, France
| | | | - Gilles Potel
- Université de Nantes, Nantes, France.,Service des Urgences, CHU de Nantes, Nantes, France
| | - Sandrine Dray
- Service de Réanimation Médicale, Hôpital Nord, CHU de Marseille, Marseille, France
| | | | - Alexandra Laurent
- Laboratoire Psy-DREPI, Université de Bourgogne Franche-Comté, EA7458, Dijon, France
| | - Agnès Ricard-Hibon
- SAMU-SMUR 95- Service des Urgences, Centre Hospitalier René Dubos, Pontoise, France
| | - Thierry Vanderlinden
- Service de Réanimation Polyvalente, Groupe Hospitalier Institut Catholique de Lille/Faculté Libre de Médecine/Université Lille Nord de France, Lille, France
| | - Tahar Chouihed
- SAMU-SMUR-Service d'Urgences, Hôpital Central, CHRU Nancy, Vandoeuvre les Nancy, France.,INSERM U1116, Université de Lorraine, Vandoeuvre les Nancy, France
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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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Walzl N, Jameson J, Kinsella J, Lowe DJ. Ceilings of treatment: a qualitative study in the emergency department. BMC Emerg Med 2019; 19:9. [PMID: 30654741 PMCID: PMC6335704 DOI: 10.1186/s12873-019-0225-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/08/2019] [Indexed: 11/29/2022] Open
Abstract
Background Decision-making concerning the limitation of potentially life-prolonging treatments is often challenging, particularly in the Emergency Department (ED). Current literature in this area of Emergency Medicine is limited and heterogeneous. We seek to determine the factors that influence ceiling of treatment institution in the ED. Methods We conducted a phenomenological qualitative study employing semi-structured interviews. Emergency Medicine Consultants were recruited via a sample of convenience from 5 hospitals in the West of Scotland. Data saturation was achieved after 15 interviews. Interviews were recorded, anonymised, transcribed, coded, and an iterative thematic analysis was carried out. Results A model was created to illustrate the identified themes. Patient wishes are central to decision-making. Acute clinical factors and patient-specific factors lay the foundations of ceiling of treatment decisions. This is heavily contextualised by family input, collateral information, anticipated outcome, and whether the patient is accepted for higher care. This decision-making process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all ceiling of treatment decisions result in one of three common patient pathways: full escalation, limited escalation, and maintenance of current care with the option of palliative care initiation. Conclusions We present a conceptual model composed of 10 major thematic factors that influence Consultant ceiling of treatment decision-making in the ED. Clinicians should be cognizant of influential factors and associated biases when making these important and challenging decisions. Electronic supplementary material The online version of this article (10.1186/s12873-019-0225-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nathan Walzl
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.
| | | | - John Kinsella
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.,Academic Unit of Anaesthesia, Pain and Critical Care Medicine, School of Medicine, University of Glasgow, Glasgow, UK
| | - David J Lowe
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.,Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
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6
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Characteristics and outcome of Emergency Department intubation in geriatric patients. Eur Geriatr Med 2018; 9:623-629. [PMID: 34654219 DOI: 10.1007/s41999-018-0085-8] [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: 03/28/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The number of elderly patients admitted to the Emergency Department (ED) continues to grow due to the natural aging of the population. Consequently, tracheal intubation will be increasingly used in the oldest old. The objective of this retrospective study is to evaluate the characteristics and outcome of patients of 75 years and older undergoing an endotracheal intubation in the ED. METHODS In a single center, retrospective study we reviewed digital medical files of patients of 75 years and older in the period from 1/01/2008 to 31/12/2010, who were admitted to the ED of the Universitair Ziekenhuis Brussel in Brussels, Belgium and underwent endotracheal intubation. Survival served as primary outcome and survival without sequelae as secondary endpoint. RESULTS In the study period, 88 patients of 75 years and older were intubated in the ED. Sixty three (72%) patients died after intubation and 25 (28%) survived until discharge. All 23 patients (26%), who were intubated during cardiopulmonary resuscitation died. A survival rate of 48% was observed in patients, who were intubated for respiratory failure (28%), intracerebral hemorrhage or ischemic stroke (17%), cardiac failure (8%) or other reasons. Non-survivors were significant older, of male sex, had higher APACHE scores and more frequently used cholesterol lowering drugs. CONCLUSION Senior adults, aged 75 years or older and undergoing endotracheal intubation at the ED, have a high mortality rate. Younger age and female sex at admission were positively correlated with survival. Of those who left the hospital, one-third were able to return home without major sequelae.
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Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T, Reignier J. Limitations et arrêts des traitements de suppléance vitale chez l’adulte dans le contexte de l’urgence. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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8
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Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T, Reignier J. Limitations et arrêts des traitements de suppléance vitale chez l’adulte dans le contexte de l’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Coombs M, Puntillo KA, Franck LS, Scruth EA, Harvey MA, Swoboda SM, Davidson JE. Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice. AACN Adv Crit Care 2018; 28:138-147. [PMID: 28592473 DOI: 10.4037/aacnacc2017766] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.
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Affiliation(s)
- Maureen Coombs
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Kathleen A Puntillo
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Linda S Franck
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Elizabeth A Scruth
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Maurene A Harvey
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Sandra M Swoboda
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Judy E Davidson
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
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Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med 2013. [PMID: 23177598 DOI: 10.1016/j.cger.2012.09.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.
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Lamba S, Mosenthal AC. Hospice and Palliative Medicine: A Novel Subspecialty of Emergency Medicine. J Emerg Med 2012; 43:849-53. [DOI: 10.1016/j.jemermed.2010.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Revised: 12/29/2009] [Accepted: 04/04/2010] [Indexed: 10/19/2022]
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13
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Verniolle M, Brunel E, Olivier M, Serres I, Mari A, Gonzalez H, Benhaoua H, Cougot P, Minville V. Évaluation des démarches de limitation et d’arrêt de traitement en salle d’accueil des urgences vitales. ACTA ACUST UNITED AC 2011; 30:625-9. [DOI: 10.1016/j.annfar.2011.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 04/20/2011] [Indexed: 10/17/2022]
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Damghi N, Belayachi J, Aggoug B, Dendane T, Abidi K, Madani N, Zekraoui A, Belabes AB, Zeggwagh AA, Abouqal R. Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: an observational study. BMC Emerg Med 2011; 11:12. [PMID: 21838861 PMCID: PMC3199862 DOI: 10.1186/1471-227x-11-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 08/12/2011] [Indexed: 11/18/2022] Open
Abstract
Background Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions. Method A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record. Results 177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases. Conclusion Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.
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Affiliation(s)
- Nada Damghi
- Medical Emergency Department, Ibn Sina University Hospital, 10000, Rabat, Morocco
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15
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Theodosiou CA, Loeffler RE, Oglesby AJ, McKeown DW, Ray DC. Rapid sequence induction of anaesthesia in elderly patients in the emergency department. Resuscitation 2011; 82:881-5. [PMID: 21440977 DOI: 10.1016/j.resuscitation.2011.02.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 02/02/2011] [Accepted: 02/14/2011] [Indexed: 11/25/2022]
Abstract
AIM Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED). METHODS We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome. RESULTS 1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients. CONCLUSION A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.
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16
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Le Conte P, Riochet D, Batard E, Volteau C, Giraudeau B, Arnaudet I, Labastire L, Levraut J, Thys F, Lauque D, Piva C, Schmidt J, Trewick D, Potel G. Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support. Intensive Care Med 2010; 36:765-72. [PMID: 20229044 DOI: 10.1007/s00134-010-1800-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 12/27/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE To describe the characteristics of patients who die in emergency departments and the decisions to withhold or withdraw life support. METHODS We undertook a 4-month prospective survey in 174 emergency departments in France and Belgium to describe patients who died and the decisions to limit life-support therapies. RESULTS Of 2,512 patients enrolled, 92 (3.7%) were excluded prior to analysis because of missing data; 1,196 were men and 1,224 were women (mean age 77.3 +/- 15 years). Of patients, 1,970 (81.4%) had chronic underlying diseases, and 1,114 (46%) had a previous functional limitation. Principal acute presenting disorders were cardiovascular, neurological, and respiratory. Life-support therapy was initiated in 1,781 patients (73.6%). Palliative care was undertaken for 1,373 patients (56.7%). A decision to withhold or withdraw life-sustaining treatments was taken for 1,907 patients (78.8%) and mostly concerned patients over 80 years old, with underlying metastatic cancer or previous functional limitation. Decisions were discussed with family or relatives in 58.4% of cases. The decision was made by a single ED physician in 379 cases (19.9%), and by at least two ED physicians in 1,528 cases (80.1%). CONCLUSIONS Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.
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Affiliation(s)
- Philippe Le Conte
- Department of Emergency Medicine, Nantes University Hospital, Nantes Cedex 01, France.
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17
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Abstract
The evolving relationship between emergency and palliative medicine is expected to benefit patients of each. Two collaborative care encounters involving home hospice patients are discussed. Portable bedside ultrasound was performed in the home to diagnose ascites and to guide palliative paracentesis. Specific interventions and outcomes are reported. The interface of emergency and palliative care and the use of paracentesis in cancer palliation are briefly reviewed. It is concluded that home-performed ultrasound and ultrasound-guided procedures are promising palliative modalities for care at the end of life.
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Affiliation(s)
- Peter J Mariani
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA.
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18
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Knapp C, Huang IC, Madden V, Vadaparampil S, Quinn G, Shenkman E. An evaluation of two decision-making scales for children with life-limiting illnesses. Palliat Med 2009; 23:518-25. [PMID: 19346274 PMCID: PMC3810449 DOI: 10.1177/0269216309104892] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses. METHODS Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses. RESULTS Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE. CONCLUSION Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.
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Affiliation(s)
- C Knapp
- Department of Epidemiology, University of Florida, Gainesville, Florida 32610, USA.
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