Understanding emergency department staff needs and perceptions in the provision of palliative care

Implementation and evaluation of a palliative care training unit for EMS providers

Background

The prevalence of children with life-limiting conditions (LLCs) is rising. It is characteristic for these children to require 24/7 care. In emergencies, families must decide to call the emergency medical service (EMS) or a palliative care team (PCT)-if available. For EMS teams, an emergency in a child with an LLC is a rare event. Therefore, EMS providers asked for a training unit (TU) to improve their knowledge and skills in pediatric palliative care.

Aim of the study

The questions were as follows: whether a TU is feasible, whether its integration into the EMS training program was accepted, and whether an improvement of knowledge can be achieved.

Methods

We designed and implemented a brief TU based on findings of a previous study that included 1,005 EMS providers. The topics covered were: (1) basics in palliative home care, (2) theoretical aspects, and (3) practical aspects. After participating in the TU, the participants were given a questionnaire to re-evaluate their learning gains and self-confidence in dealing with emergencies in pediatric patients with LLC.

Results

782 (77.8%) of 1,005 participants of the previous study responded to the questionnaire. The average age was 34.9 years (±10.7 years SD), and 75.3% were male. The average work experience was 11.4 years (±9.5 years SD), and 15.2% were medical doctors. We found an increase in theoretical knowledge and enhanced self-confidence in dealing with emergencies in patients with LLC (confidence: before training: 3.3 ± 2.0 SD; after training: 5.7 ± 2.1 SD; min.: 1; max.: 10; p < 0.001). The participants changed their approaches to a fictitious case report from more invasive to less invasive treatment. Most participants wanted to communicate directly with PCTs and demanded a standard operating procedure (SOP) for treating patients with LLC. We discussed a proposal for an SOP with the participants.

Conclusion

EMS providers want to be prepared for emergencies in children with LLCs. A brief TU can improve their knowledge and confidence to handle these situations adequately. This TU is the first step to improve collaboration between PCTs and EMS teams.

Attitudes and knowledge of emergency doctors towards end-of-life care in the emergency department: a national survey

BACKGROUND

Emergency departments (EDs) are seeing an increase in patients requiring end-of-life (EOL) care. There is paucity of data of attitudes and knowledge of physicians providing EOL care in the ED both internationally and in Ireland.

OBJECTIVE

The aim of this project was to assess the attitudes and knowledge of ED physicians towards EOL care.

METHODS

This was a cross-sectional electronic survey of ED physicians working in Irish EDs and was facilitated through the Irish Trainee Emergency Research Network over a 6-week period. The questionnaire covered the following domains: demographic data, awareness of EOL Care, views and attitudes towards EOL care.

RESULTS

Of a potential 679 respondents, 441 responses were received, of which 311 (response rate of 44.8%) had fully completed the survey across 23 participant sites. Majority of the respondents were under the age of 35 (62%), were male (58%) and at Senior House Officer level (36%). In terms of awareness, 32% (98) of respondents were not aware of palliative care services in their hospitals while only 29% (91) were aware of national EOL guidance. Fifty-five percent (172) reported commencing EOL care in the ED, however 75.5% (234) respondents reported their knowledge of EOL care to be limited or non-existent. Only 30.2% respondents felt comfortable commencing EOL care in the ED without speciality team input. There appears to be a lack of clarity on the roles and responsibilities of emergency medicine nurses and doctors in the care of the dying patient in ED with only 31.2% (95) being clear on this role. Significant differences were observed associated with clinical experience and physician grade.

CONCLUSION

This study has highlighted a lack of awareness and knowledge of EOL care particularly amongst less experienced emergency medicine doctors. Formalized training and education programs in the provision of EOL care in the ED will improve comfort levels and knowledge amongst the emergency medicine doctors and improve the quality of care provided.

Prehospital emergency medicine for children receiving palliative home care in Germany-a cross-sectional, exploratory study of EMS providers

BACKGROUND

The prevalence of children with life-limiting conditions is rising, and since the amendment of the social insurance code in Germany, palliative home care teams have treated an increasing number of children. These teams provide 24/7 readiness, yet some parents still call the general emergency medical service (EMS) for various reasons. EMS is exposed to complex medical problems in rare diseases. Questions arose about the experiences of EMS and whether they felt prepared for emergencies involving children treated by a palliative care team.

METHODS

This study used a mixed methods approach to focus on the interface between palliative care and EMS. First, open interviews were conducted, and a questionnaire was developed based on the results. The variables included demographic items and individual experiences with patients. Second, a case report of a child with respiratory insufficiency was presented to assess the spontaneous treatment intentions of EMS providers. Finally, the need, relevant topics, and duration of specific training in palliative care for EMS providers were evaluated.

RESULTS

In total, 1,005 EMS providers responded to the questionnaire. The average age was 34.5 years (±10.94SD), 74.6% were male. The average work experience was 11.8 years (±9.7), 21.4% were medical doctors. Experience with a call of a life-threatening emergency involving a child was reported by 61.5% and severe psychological distress during such a call was reported by 60.4%. The equivalent distress frequency for adult patient calls was 38.3%. (p < 0.001). After review of the case report, the EMS respondents suggested invasive treatment options and rapid transport to the hospital. Most (93.7%) respondents welcomed the consideration of special training in pediatric palliative care. This training should include basic information about palliative care, an analysis of cases involving palliatively treated children, an ethical perspective, practical recommendations, and available (24/7) local contact for further guidance and support.

CONCLUSION

Emergencies in pediatric palliatively treated patients were more common than expected. EMS providers perceived the situations as stressful, and there is a need for specific training with practical aspects.

Experiences of emergency department nurses using palliative care resources and associated tools in the provision of quality care of a dying patient

Access to quality palliative and end-of-life care in the emergency department is as vitally important as care at any other stage of life. This study aimed to investigate nurses' perceptions of the use of a suite of dedicated resources to support the provision of care to patients who are dying in the emergency environment. The study followed a qualitative descriptive design; 11 semi-structured interviews were conducted and analysed using thematic coding. Five themes were developed: facilitating care delivery; comfort and environmental adjustments; visual symbolism; developing knowledge to overcome fear; and perceptions of family experiences. There is an increasing need to access palliative care in the emergency department; the use of a suite of resources can play an important role in the provision of quality care to the dying.

Aotearoa New Zealand emergency medicine specialists on the provision of care at or near the end of life: A survey

OBJECTIVES

The ED is an increasingly important venue for the initiation of palliative care. We sought to characterise the opinions, experience, training and education of ED staff in Aotearoa/New Zealand (NZ) with regard to specific aspects of palliative care in the NZ ED setting.

METHODS

All NZ FACEMs were personally emailed a simple unstructured 16-part survey asking questions about initiating palliative care, goals of care, initiation and availability of advance care plans, frailty screening, availability of palliative expertise, training and education, cultural safety and pastoral care of staff. All EDs were contacted and a link provided for non-FACEM ED staff who wished to participate. Free-text comments were analysed for dominant themes.

RESULTS

All NZ EDs had at least one participant. There was a high level of senior medical staff engagement with 60% of NZ FACEMs participating. More than 300 free-text comments from this group were available for theme analysis. A total of 93% of NZ FACEM respondents agree that palliative care should be able to be initiated in the ED. Only 25% of this group knew of training in serious illness conversations in the ED while only 34% felt culturally competent when providing end-of-life care for Māori and their whanau (family). Pastoral care for ED staff appears to be ad hoc. Time and privacy limitations were common themes.

CONCLUSIONS

There is significant opportunity for quality improvement in the initiation and provision of palliative care from the ED. Attention to how departments provide pastoral care to their staff is needed.

End-of-Life Communication in the Emergency Department: The Emergency Physicians' Perspectives

Introduction:

End-of-life (EOL) conditions are commonly encountered by emergency physicians (EP). We aim to explore EPs’ experience and perspectives toward EOL discussions in acute settings.

Methods:

A qualitative survey was conducted among EPs in three tertiary institutions. Data on demographics, EOL knowledge, conflict management strategies, comfort level, and perceived barriers to EOL discussions were collected. Data analysis was performed using SPSS and SAS.

Results:

Of 63 respondents, 40 (63.5%) were male. Respondents comprised 22 senior residents/registrars, 9 associate consultants, 22 consultants, and 10 senior consultants. The median duration of emergency department practice was 8 (interquartile range: 6–10) years. A majority (79.3%) reported conducting EOL discussions daily to weekly, with most (90.5%) able to obtain general agreement with families and patients regarding goals of care. Top barriers were communications with family/clinicians, lack of understanding of palliative care, and lack of rapport with patients. 38 (60.3%) deferred discussions to other colleagues (e.g., intensivists), 10 (15.9%) involved more family members, and 13 (20.6%) employed a combination of approaches. Physician's comfort level in discussing EOL issues also differed with physician seniority and patient type. There was a positive correlation between the mean general comfort level when discussing EOL and the seniority of the EPs up till consultancy. However, the comfort level dropped among senior consultants as compared to consultants. EPs were most comfortable discussing EOL of patients with a known terminal illness and least comfortable in cases of sudden death.

Conclusions:

Formal training and standardized framework would be useful to enhance the competency of EPs in conducting EOL discussions.

What is a compassionate response in the emergency department? Learner evaluation of an End-of-Life Essentials online education module

Objective

To evaluate the End‐of‐Life Essentials education module ‘Emergency Department End‐of‐Life Care’ and explore learners' views on what constitutes a compassionate response in the ED.

Methods

The present study used a multi‐methods approach. Learners comprised a mix of nurses, doctors and allied health professionals. A quantitative pre‐post evaluation analysis of learners' (n = 959) knowledge, skills, attitude and confidence was conducted, along with a qualitative thematic content analysis on learner responses (n = 538) to the post‐evaluation question, ‘What is a compassionate response for you in the emergency department?’ Data were extracted for a 12‐month period, 6 May 2019 to 6 May 2020.

Results

Learners' post‐evaluation ranks of knowledge, skill, attitude and confidence were significantly higher than the pre‐evaluation ranks (P < 0.001). Emerging themes from the qualitative data were organised into three overarching categories: communication skills (e.g. listening and use of names), care discussion and provision (e.g. provide information and discuss care plans) and humanising healthcare (e.g. emotional support and empathy, taking the time, and offering kindness and comfort).

Conclusion

The ‘Emergency Department End‐of‐Life Care’ module had a significant positive impact on learners in relation to perceived knowledge, skill, attitude and confidence. This evaluation suggests that the End‐of‐Life Essentials ED module could be a useful online learning resource for health professionals.

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

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.

Nurses Training and Capacitation for Palliative Care in Emergency Units: A Systematic Review

Background and objectives: Palliative care (PC) prevents and alleviates patients´ suffering to improve their quality of life in their last days. In recent years, there has been an increase in visits to the emergency services (ES) by patients who may need this type of care. The aims were to describe the training and capacitation of nurses from ES in PC. Accordingly, a systematic review was performed. Materials and Methods: Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were used. The search equation was “Palliative care and nursing care and emergency room”. A total of 12 studies were selected. Results: The studies agree on the need for training professionals in PC to provide a higher quality care, better identification of patient needs and to avoid unnecessary invasive processes. Similarly, the implementation of a collaborative model between ES and PC, the existence of a PC specialized team in the ES or proper palliative care at home correspond to a decrease in emergency visits, a lower number of hospitalizations or days admitted, and a decrease in hospital deaths. Conclusions: The development of PC in the different areas of patient care is necessary. Better palliative care leads to a lower frequency of ES by terminal patients, which has a positive impact on their quality of life. Access to PC from the emergency unit should be one of the priority health objectives due to increment in the aged population susceptible to this type of care.

Palliative care in the emergency department: A survey assessment of patient and provider perspectives

BACKGROUND

Palliative care has been identified as an area of low outpatient referral from our emergency department, yet palliative care has been shown to improve the quality of patient's lives.

AIM

This study investigates both provider and patient perspectives on palliative care for the purpose of identifying barriers to increased palliative care utilization within our healthcare system.

DESIGN

Two surveys were developed, one for patients/caregivers and one for healthcare providers.

SETTING/PARTICIPANTS

This was a single-center study completed at a quaternary academic emergency department. A survey was sent to emergency medicine providers with 47% response rate. Research staff approached Emergency Department patients who had been identified to be high risk to fill out paper surveys with 76% response rate.

RESULTS

Only 28% of patients had already undergone palliative care, with an additional 25% interested in palliative care. Nearly half of the patients felt that they needed more resources to prevent hospital visits. Patients identified low understanding of palliative care and difficulty accessing appointments as barriers to consultation. Among providers, 98% indicated that they had patients who would benefit from palliative care. A majority of providers highlighted patient understanding of palliative care and access to appointments as barriers to palliative care. Notably, 52% of providers reported that emergency medicine provider knowledge was a barrier to palliative care consultation.

CONCLUSIONS

Despite emergency department patients' self-identified need for resources and emergency medicine providers' recognition of patients who would benefit from palliative care, few patients receive palliative care consultation.

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases

Introduction

The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment.

Methods

Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis.

Results

We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver's emotions, coping and understanding of patient's illness, patient's wishes, coping and understanding of patient's illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians' knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested.

Conclusion

Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

Palliative care in the emergency department as seen by providers and users: a qualitative study

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.

Harmonizing Palliative Care: National Survey to Evaluate the Knowledge and Attitude of Emergency Physicians towards Palliative Care.. [DOI: 10.1101/19003939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and Aim

Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians (EPs) and their accessibility to palliative care services in Kuwait. So the aim of this study was to explore the attitude, and knowledge encountered by 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 Palliative Care Attitude and Knowledge (PCAK) 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 either uncertain attitude toward palliative care. Most of the EPs (n=73, 70.28%) didn’t discuss the need of the patients to palliative care either with the patients or their families. Only 16 (15.4%) of the EPs responded correctly to the most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge especially in the most effective management of refractory dysnea (n=18, 17.3%). Experience ≥ 11yrs and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position, and nationality [OR: 5.747 (CI: 1.031-25.00), 1.458(CI: 1.148-1.851); p-value: 0.021, 0.002 respectively]..

Conclusions

Despite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude. Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.

What this paper adds

Studies proved that the emergency room may be a suitable place for early referral of patients who may benefit from palliative care especially old age to prevent upcoming undesired admissions and hospital deaths.

The integration of palliative care concepts and consultation teams into emergency medicine may help to avoid unnecessary and burdensome treatments, tests, and procedures that are not aligned with patients’ goals of care.

Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians and their accessibility to palliative care services in Kuwait.

Recently, a newly developed tool called Palliative Care Attitude and Knowledge (PCAK) questionnaire was created to assess the attitude and knowledge of non-palliative physicians toward palliative care. So the aim of this study was to explore the attitude, and knowledge encountered by emergency physicians in providing palliative care using PCAK 8 in emergency departments in all general

Studies showed that early palliative care consultation was shown to improve quality of life for cancer patients and may even lengthen their survival.

What this study adds

Despite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude.

Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.

Prevalence of palliative care patients in emergency departments

BACKGROUND

Emergency departments (ED) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far.

METHODS

In the ED of a tertiary care medical centre in Carinthia all adult patients presenting between 8 January 2018 and 17 January 2018 were classified on arrival with the Manchester triage system (MTS) and were afterwards assessed with a validated 2‑tier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care.

RESULTS

In total 1277 patients visited the ED during the investigation period. Of these patients 1096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only 8 (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation.

CONCLUSIONS

More than 1 in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that healthcare providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.

End-of-Life Care Challenges from Staff Viewpoints in Emergency Departments: Systematic Review

The hospital emergency department (ED) is the place where people most commonly seek urgent care. The initial diagnosis of an end-of-life (EOL) condition may occur in the ED. In this review we described the challenges; from the staff members’ perspectives, to safe, appropriate, and high quality end-of-life care (EOLC) for people who are diagnosed with non-malignant diseases who present to ED settings internationally. We conducted a systematic review of peer-reviewed literature. PubMed, Scopus, CINAHL, Medline, and Web of Science were searched from 2007 to 2017. In this review the challenges in providing quality EOLC from staff viewpoints, for EOL people who are diagnosed with non-malignant progressive diseases in ED settings, were classified into eight themes: (1) EOLC education and training, (2) ED design, (3) Lack of family support, (4) Work Load, (5) ED staff communication and decision making, (6) EOLC quality in ED, (7) resource availability (time, space, appropriate interdisciplinary personnel) and (8) integrating palliative care (PC) in ED. The formulation of EOLC using this review result may help to improve the quality of life for dying people by providing ED staff with clear guidelines that can guide them in their daily practice

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department

STUDY OBJECTIVE

Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).

METHODS

This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.

RESULTS

A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).

CONCLUSION

Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

Palliative care needs of advanced cancer patients in the emergency department at the end of life: an observational cohort study

PURPOSE

Patients with advanced cancer commonly visit the emergency department (ED) during the last 3 months of life. Identification of these patients and their palliative care needs help initiating appropriate care according to patients' wishes. Our objective was to provide insight into ED visits of advanced cancer patients at the end of life.

METHODS

Adult palliative patients with solid tumours who died < 3 months after their ED visit were included (2011-2014). Patients, ED visits, and follow-up were described. Factors associated with approaching death were assessed using Cox proportional hazards models.

RESULTS

Four hundred twenty patients were included, 54.5% was male, median age 63 years. A total of 54.6% was on systemic anti-cancer treatments and 10.5% received home care ≥ 1 per day. ED visits were initiated by patients and family in 34.0% and 51.9% occurred during out-of-office hours. Dyspnoea (21.0%) or pain (18.6%) were most reported symptoms. Before the ED visit, limitations on life-sustaining treatments were discussed in 33.8%, during or after the ED visit in 70.7%. Median stay at the ED was 3:29 h (range 00:12-18:01 h), and 319 (76.0%) were hospitalized. Median survival was 18 days (IQ range 7-41). One hundred four (24.8%) died within 7 days after the ED visit, of which 71.2% in-hospital. Factors associated with approaching death were lung cancer, neurologic deterioration, dyspnoea, hypercalcemia, and jaundice.

CONCLUSION

ED visits of advanced cancer patients often lead to hospitalization and in-hospital deaths. Timely recognition of patients with limited life expectancies and urgent palliative care needs, and awareness among ED staff of the potential of ED-initiated palliative care may improve the end-of-life trajectory of these patients.

Palliative Care in the Pediatric Emergency Department: Findings From a Qualitative Study

STUDY OBJECTIVE

Children with medical complexity represent a fragile population and account for the majority of patients followed in pediatric palliative care. Little is known in regard to the role of the emergency department (ED) in caring for the families of children with medical complexity.

METHODS

Semistructured focus groups were held with health care professionals from pediatric emergency medicine, palliative care, complex care, and intensive care to explore their perspective on pediatric palliative care in the ED. Data were transcribed and analyzed with NVivo software, and thematic analysis and theoretic sampling were performed.

RESULTS

From January to October 2016, 58 participants were interviewed. Difficulties providing pediatric palliative care in the ED are related on the one hand to characteristics specific to the ED, such as its culture and its health care professionals' strong emotional responses when caring for children with medical complexity, and on the other hand to factors extrinsic to the ED; mainly, lack of continuity of care. For critically ill children with unknown goals of care and potential for end of life, professionals in the ED should evaluate the clinical situation, contact known health care teams, remain open to families' preferences, alleviate distressing symptoms, and create a caring environment. Communication between teams is targeted by health care professionals to facilitate and improve patient flow and care.

CONCLUSION

Although perspectives differ in regard to how to provide care for pediatric palliative care patients in the ED, several barriers to providing high-quality emergency pediatric palliative care can be overcome.

Initiating End-of-Life Care at the Emergency Department: An Observational Study

OBJECTIVE

Terminally ill patients at their end-of-life (EOL) phase attending the emergency department (ED) may have complex and specialized care needs frequently overlooked by ED physicians. To tailor to the needs of this unique group, the ED in a tertiary hospital implemented an EOL pathway since 2014. The objective of our study is to describe the epidemiological characteristics, symptom burden and management of patients using a protocolized management care bundle.

METHODS

We conducted an observational study on the database of EOL patients over a 28-month period. Patients aged 21 years and above, who attended the ED and were managed according to these guidelines, were included. Clinical data were extracted from the hospital's electronic medical records system.

RESULTS

Two hundred five patients were managed under the EOL pathway, with a slight male predominance (106/205, 51.7%) and a median age of 78 (interquartile range 69-87) years. The majority were chronically frail (42.0%) or diagnosed with cancer or other terminal illnesses (32.7%). The 3 most commonly experienced symptoms were drowsiness (66.3%), dyspnea (61.5%), and fever (29.7%). Through the protocolized management care bundle, 74.1% of patients with dyspnea and/or pain received opiates while 59.5% with copious secretions received hyoscine butylbromide for symptomatic relief.

CONCLUSION

The institution of a protocolized care bundle is feasible and provides ED physicians with a guide in managing EOL patients. Though still suboptimal, considerable advances in EOL care at the ED have been achieved and may be further improved through continual education and enhancements in the care bundle.

Palliative care in the emergency department: A systematic literature qualitative review and thematic synthesis

BACKGROUND

Despite a fast-paced environment, the emergency clinician has a duty to meet the palliative patient's needs. Despite suggested models and interventions, this remains challenging in practice.

AIM

To raise awareness of these challenges by exploring the experience of palliative care patients and their families and informal carers attending the emergency department, and of the clinicians caring for them.

DESIGN

Qualitative systematic literature review and thematic synthesis. Search terms related to the population (palliative care patients, family carers, clinicians), exposure (the emergency department) and outcome (experience). The search was international but restricted to English and used a qualitative filter. Title, abstracts and, where retrieved, full texts were reviewed independently by two reviewers against predefined inclusion criteria arbitrated by a third reviewer. Studies were appraised for quality but not excluded on that basis.

DATA SOURCES

MEDLINE [1946-], Embase[1947-], CINAHL [1981-] and PsycINFO [1987-] with a bibliography search.

RESULTS

19 papers of 16 studies were included from Australia ( n = 5), the United Kingdom ( n = 5), and United States ( n = 9) representing 482 clinical staff involved in the emergency department (doctors, nurses, paramedics, social workers, technicians), 61 patients and 36 carers. Nine descriptive themes formed three analytic themes: 'Environment and Purpose', 'Systems of Care and Interdisciplinary Working' and 'Education and Training'.

CONCLUSION

In the included studies, provision of emergency palliative care is a necessary purpose of the emergency department. Failure to recognise this, gain the necessary skills or change to systems better suited to its delivery perpetuates poor implementation of palliative care in this environment.

Emergency department staff priorities for improving palliative care provision for older people: A qualitative study

BACKGROUND

Emergency department-based palliative care services are increasing, but research to develop these services rarely includes input from emergency clinicians, jeopardizing the effectiveness of subsequent palliative care interventions.

AIM

To collaboratively identify with emergency clinicians' improvement priorities for emergency department-based palliative care for older people.

DESIGN

This was one component of an experience-based co-design project, conducted using semi-structured interviews and feedback sessions.

SETTING/PARTICIPANTS

In-depth interviews with 15 emergency clinicians (nurses and doctors) at a large teaching hospital emergency department in the United Kingdom exploring experiences of palliative care delivery for older people. A thematic analysis identified core challenges that were presented to 64 clinicians over five feedback sessions, validating interview findings, and identifying shared priorities for improving palliative care delivery.

RESULTS

Eight challenges emerged: patient age; access to information; communication with patients, family members, and clinicians; understanding of palliative care; role uncertainty; complex systems and processes; time constraints; and limited training and education. Through feedback sessions, clinicians selected four challenges as improvement priorities: time constraints; communication and information; systems and processes; and understanding of palliative care. As resulting improvement plans evolved, "training and education" replaced "time constraints" as a priority.

CONCLUSION

Clinician priorities for improving emergency department-based palliative care were identified through collaborative, iterative processes. Though generally aware of older palliative patients' needs, clinicians struggled to provide high-quality care due to a range of complex factors. Further research should identify whether priorities are shared across other emergency departments, and develop, implement, and evaluate strategies developed by clinicians.

Experiences of healthcare professionals in providing palliative end-of-life care to patients in emergency departments: a systematic review protocol

The objective of this review is to identify and synthesize the best available evidence on the experiences of healthcare professionals in providing palliative care to patients at the end of life in emergency departments.

Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol

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?

The Integration of Palliative Care into the Emergency Department

Palliative care (PC) is a new and developing area. It aims to provide the best possible quality of life for patients with life-limiting diseases. It does not primarily include life-extending therapies, but rather tries to help patients spend the rest of their lives in the best way. PC patients often are admitted to emergency departments during the course of a disease. The approach and management of PC include differences with emergency medicine. Thus, there are some problems while providing PC in the ED. With this article, the definition, main features, benefits, and problems of providing PC are presented, with the primary aim of emphasizing the importance of PC integration into the ED.

Lived experience of caring for dying patients in emergency room

BACKGROUND

Dying often occurs in hospitals and frequently in emergency rooms. Understanding caring for critical and dying patients is necessary for quality nursing.

PURPOSE

This study described the meaning of nurses' lived experience of caring for critical and dying patients in the emergency rooms.

METHODS

This study was conducted in three emergency rooms of tertiary hospitals in southern Thailand. Twelve nurses met the inclusion criteria: nurses working in emergency room for at least 2 years, and experienced caring for critical and dying patients in an emergency department. Data were collected using in-depth individual interviews. Data transcription and analysis used van Manen's hermeneutic phenomenological approach. Trustworthiness was established following Lincoln and Guba's criteria.

FINDINGS

Experiences of caring for critical and dying patients revealed four thematic categories: defying death; no time for palliative care; lacking support for family; and privacy for peaceful deaths. These thematic categories reflected van Manen's four lived worlds of body, time, relations and space.

CONCLUSIONS

The study described the meaning of the experience of caring for critical and dying patients while supporting the development of nursing knowledge for palliative and end-of-life care in emergent settings.

IMPLICATIONS FOR NURSING POLICY

Findings of the study influence nursing policies toward enhancing education of nurses regarding palliative and end-of-life care in emergency settings. These findings can also influence the value of caring-healing environments for critical and dying patients and their families. Policies can focus on practice and education of families particularly about end-of-life care for critical and dying patients.

Community-based palliative care is associated with reduced emergency department use by people with dementia in their last year of life: A retrospective cohort study

OBJECTIVE

To describe patterns in the use of hospital emergency departments in the last year of life by people who died with dementia and whether this was modified by use of community-based palliative care.

DESIGN

Retrospective population-based cohort study of people in their last year of life. Time-to-event analyses were performed using cumulative hazard functions and flexible parametric proportional hazards regression models.

SETTING/PARTICIPANTS

All people living in Western Australia who died with dementia in the 2-year period 1 January 2009 to 31 December 2010 (dementia cohort; N = 5261). A comparative cohort of decedents without dementia who died from other conditions amenable to palliative care (N = 2685).

RESULTS

More than 70% of both the dementia and comparative cohorts attended hospital emergency departments in the last year of life. Only 6% of the dementia cohort used community-based palliative care compared to 26% of the comparative cohort. Decedents with dementia who were not receiving community-based palliative care attended hospital emergency departments more frequently than people receiving community-based palliative care. The magnitude of the increased rate of emergency department visits varied over the last year of life from 1.4 (95% confidence interval: 1.1-1.9) times more often in the first 3 months of follow-up to 6.7 (95% confidence interval: 4.7-9.6) times more frequently in the weeks immediately preceding death.

CONCLUSIONS

Community-based palliative care of people who die with or of dementia is relatively infrequent but associated with significant reductions in hospital emergency department use in the last year of life.

Staff perceptions of palliative care in a public Australian, metropolitan emergency department

OBJECTIVE

The primary aim was to investigate staff experiences and attitudes towards palliative care provision in a public metropolitan ED.

METHODS

Using a previously validated survey tool, data were collected from ED clinical staff using Likert-type, open-ended and dichotomous items asking about perceptions of palliative care and education needs. Comparisons were made between nursing and medical staff.

RESULTS

Medical staff and nurses' perceptions of palliative care were similar, differing on only 10 of 37 (Likert) items. All staff reported confidence with symptom management, whereas medical staff felt more confident with decision-oriented communication and nurses were more supportive of nasogastric feeding. Staff were moderately accurate in determining the five most common causes of death. Four out of five conditions selected as appropriate for palliative care were cancer diagnoses. End-of-life communication and ethical issues were the two most frequently requested areas for further education.

CONCLUSIONS

Our study suggests that overall ED staff were confident regarding symptom management in palliative care. Cancer diagnoses were overrepresented in both the top five causes of death and conditions most appropriate for a palliative approach, suggesting that staff might underestimate the role of a palliative approach in non-cancer diagnoses. Areas suggested for further education include communication and ethical issues surrounding end-of-life care.

Emergency medicine and palliative care

The emergency department cares for seriously ill patients across the trajectory of illness from diagnosis to death or cure. Emergency departments participate in critical illness trajectories that include initiation of life-sustaining therapies as well as caring for patients and families in their final moments of life. Emergency clinicians are uniquely poised to identify critical palliative care interventions to be used when patients and families are most in need with respect to symptom management, decisions regarding intervention and procedures to sustain life and participate in critically important decisions regarding withdrawing and withholding nonbeneficial life-sustaining therapies.