A model for emergency department end-of-life communications after acute devastating events--part II: moving from resuscitative to end-of-life or palliative treatment

The Health Service Model for Promoting Good Death in Critically Ill End-of-Life Patients in the Emergency Department: A Qualitative Study

Good death is one of the important outcomes of end-of-life care service delivery. The initial management of critically ill patients in the Emergency Department (ED) for promoting good death often challenging since it requires a focus on human dignity and equity at the end of life. A qualitative approach was used included eight bereaved family members who loss of their loved one in the ED and 25 emergency staff, including 11 emergency physicians and 14 emergency nurses of a super tertiary hospital in Thailand. Semi-structured, face-to-face interviews were conducted from February to August 2021. All the interviews were transcribed verbatim for content analysis. The result identified four distinct scenarios and seven core themes of end-of-life patient characteristics in the ED. To promote a good death in the ED, health care provider should consider the unique service deliver for each critically end-of-life patients and their family members.

Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention

Background

Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework.

Methods

Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM.

Results

The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use.

Conclusions

An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.

Differences in Characteristics, Hospital Care, and Outcomes between Acute Critically Ill Emergency Department Patients Receiving Palliative Care and Usual Care

Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.

Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review

AIM

Pre-mortem interventions (PMIs) are performed on patients before the determination of death in order to preserve or enhance the possibility of organ donation. These interventions can be ethically controversial, and we thus undertook a scoping review of the ethical issues surrounding diverse PMIs.

METHODS

Using modified scoping review methods, we executed a search strategy created by an information specialist. Screening and iterative coding of each article was done by two researchers using qualitative thematic analysis, and narrative summaries of coded themes were presented.

RESULTS

We identified and screened 5365 references and coded 196 peer-reviewed publications. The most frequently cited issues were related to possible harms to the patient who is a potential donor, and legitimacy of consent. The most controversial issue was that PMIs may place patients at risk for physical harm, yet benefit is accrued mainly to recipients. Some authors argued that lack of direct medical benefit to the still living patient precluded valid consent from surrogate decision makers (SDMs), while many stated that some medical risk could be approved by SDMs if it aligns with non-medical benefits valued by the patient.

CONCLUSION

PMIs require consensus that benefit includes concepts beyond medical benefit to the patient who is a potential donor. Informed consent must be confirmed for each PMI and not assumed to be part of general consent for donation. Risk must be proportionate to the potential benefit and newly proposed interventions should be reviewed carefully for medical efficacy and potential risks.

Increasing Awareness of Palliative Medicine With the Emergency Department: A Quality Improvement Project

Palliative medicine can be essential in helping to align patients' goals of care with their treatment team. Referrals for palliative medicine are more advantageous when initiated in the emergency department as this is the first point of contact for seriously ill patients being admitted to the hospital. This paper highlights a quality improvement project initiated to address knowledge gaps in palliative medicine with emergency department (ED) staff and to increase referrals for palliative medicine from the ED. The palliative medicine staff held an in-service training with the ED staff which focused on defining palliative medicine and the importance of early consults when the patient presents in the ED. Palliative medicine staff also highlighted the differences between palliative medicine and hospice care, when and how to initiate a consult for palliative medicine, as well as how to contact the palliative medicine division. The results showed that after this educational intervention the number of palliative medicine consults increased three-fold. Before the educational intervention, monthly averages for palliative medicine were 6 and after rose to 18.9 per month.

Emergency Healthcare Providers' Knowledge about and Attitudes toward Advance Directives: A Cross-Sectional Study between Nurses and Emergency Medical Technicians at an Emergency Department

This study aimed to explore and compare knowledge levels about advance directives (ADs) and life-sustaining treatment (LST) plans in end-of-life patients between emergency nurses and emergency medical technicians (EMTs). Using a cross-sectional study design and convenience sampling, 96 nurses and 68 EMTs were recruited from 12 emergency medical centers. A survey on knowledge about and attitudes toward ADs was performed using both online and offline methods between November and December 2019. Emergency healthcare providers were conceptually knowledgeable regarding ADs and LST, although approximately half or fewer had knowledge about ADs (such as the legal process for preparation, family or healthcare providers’ role, and the healthcare proxy). The knowledge levels of nurses and EMTs were moderate. Nurses had significantly greater knowledge relative to EMTs about ADs and LST. Positive attitudes of emergency healthcare providers were also moderately low, with nurses having less positive views than EMTs. Significant differences regarding ADs were found, with younger emergency healthcare providers having fewer career years, no personal end-of-life experiences, and less need for ADs having less knowledge. Emergency healthcare providers’ knowledge about and attitudes toward ADs were moderately low, with EMTs demonstrating a greater knowledge deficit and nurses exhibiting lower positive attitudes. Younger and novice providers had lower knowledge, but younger providers had more positive attitudes, implying that professional education and training should begin early in their careers to enhance their confidence for emergency delivery of advanced care planning.

Deaths in the Emergency Department: An Assessment of Patient's End-of-Life Trajectory and Quality of Care

Background:

A considerable proportion of deaths occur in the emergency department (ED), and yet a palliative care approach is not well integrated. End-of-life patients often either receive invasive care, or their care is neglected due to being perceived as not being “acutely” ill. While a small proportion of these deaths are of an unpredictable nature, most have identifiable dying trajectories: (a) advanced cancer, (b) organ failure, (c) chronic frailty, and (d) sudden death.

Aims:

This study aims (1) to determine the incidence, nature and illness trajectory of deaths in the ED; (2) to examine to which extent end of life discussions took place; (3) to analyze the aggressiveness of the care; and (4) to determine if palliative care services were being consulted.

Methods:

This retrospective study was conducted in a large tertiary hospital and cancer center in Saudi Arabia over a 1 year period. Data collection included demographics, clinical presentation, end-of-life care, and palliative care involvement.

Results:

Our study included 103 patients. Cancer was the main diagnosis (45.7%). Deaths were related to advanced cancer (45.6%), followed by organ failure (29.1%), sudden death (13.6%), and chronic frailty (11.7%,). 35.9% had a documented Do-Not-Attempt-Resuscitation (DNAR) status prior to admission. 51.5% received aggressive treatments. Palliative care was consulted for 19.4% of patients, among which 50% of referrals occurred 1 day prior to death.

Conclusions:

End-of-life care discussions tend to occur late in the disease trajectory; a number of patients are subjected to aggressive treatments, and palliative care services remain underutilized. An early, integrated and collaborative approach is warranted to address the challenges of end of life care.

Harmonising palliative care: a national survey to evaluate the knowledge and attitude of emergency physicians towards palliative care in Kuwait

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.

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.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Palliative care in the emergency department: an educational investigation and intervention

BACKGROUND

To investigate the value of a novel simulation-based palliative care educational intervention within an emergency medicine (EM) residency curriculum.

METHODS

A palliative care scenario was designed and implemented in the simulation program at an urban academic emergency department (ED) with a 3-year EM residency program. EM residents attended one of eight high-fidelity simulation sessions, in groups of 5-6. A standardized participant portrayed the patient's family member. One resident from each session managed the scenario while the others observed. A 45-min debriefing session and small group discussion followed the scenario, facilitated by an EM simulation faculty member and a resident investigator. Best practices in palliative care were highlighted along with focused learner performance feedback. Participants completed an anonymous pre/post education intervention survey.

RESULTS

Forty of 42 EM residents (95%) participated in the study. Confidence in implementing palliative care skills and perceived importance of palliative care improved after this educational intervention. Specifically, residents 1) felt EM physicians had an important role in palliative care, 2) had increased confidence in the ability to determine patient decision-making capacity, 3) had improved confidence in initiating palliative discussions/treatment, 4) believed palliative education was important in residency, and 5) felt simulation was an effective means to learn palliative care. Differences noted between PGY1 and PGY 3 training levels in survey responses disappeared post-intervention. Residents noted being most comfortable with delivering bad news and symptom management and least comfortable with disease prognostication. Residents reported time constraints and implementation logistics in the ED as the most challenging factors for palliative care initiation.

CONCLUSION

Our case-based simulation intervention was associated with an increase in both the perceived importance of ED palliative care and self-reported confidence in implementing palliative care skills. Time constraints and implementation logistics were rated as the most challenging factors for palliative care initiation in the ED.

Characterization, conservation and loss of dignity at the end-of- life in the emergency department. A qualitative protocol

AIMS

To explore and understand the experiences of terminally ill patients and their relatives regarding dignity during end-of-life care in the emergency department.

BACKGROUND

The respect given to the concept of dignity is significantly modifying the clinical relationship and the care framework involving the end-of-life patient in palliative care units, critical care units, hospices and their own homes. This situation is applicable to in-hospital emergency departments, where there is a lack of research which takes the experiences of end-of-life patients and their relatives into account.

DESIGN

A phenomenological qualitative study.

METHODS

The protocol was approved in December 2016 and will be carried out from December 2016-December 2020. The Gadamer's philosophical underpinnings will be used in the design and development of the study. The data collection will include participant observation techniques in the emergency department, in-depth interviews with terminally ill patients and focus groups with their relatives. For the data analysis, the field notes and verbatim transcriptions will be read and codified using ATLAS.ti software to search for emerging themes.

DISCUSSION

Emerging themes that contribute to comprehending the phenomenon of dignity in end-of-life care in the emergency department are expected to be found. This study's results could have important implications in the implementation of new interventions in emergency departments. These interventions would be focused on improving: the social acceptance of death, environmental conditions, promotion of autonomy and accompaniment and assumption (takeover) of dignified actions and attitudes (respect for human rights).

Defining dignity in end-of-life care in the emergency department

Background:

Respecting dignity is having a profound effect on the clinical relationship and the care framework for terminally ill patients in palliative care units, hospices and their own homes, with particular consequences for the emergency department. However, dignity is a vague and multifaceted concept that is difficult to measure.

Objective:

The aim of this study is to define the attributes of dignity in end-of-life care in the emergency department, based on the opinions of physicians and nurses.

Research design:

A hermeneutic phenomenological approach utilising Gadamer's philosophical underpinnings guided the study.

Participants and research context:

This research was conducted in Spain in 2013–2014. Participants included 10 physicians and 16 nurses with experience working in the emergency department. Two focus groups and 12 in-depth interviews were carried out.

Ethical considerations:

The study was approved by the Research Centre Ethical Committee (Andalusian Health Service, Spain).

Findings:

The results point to the person's inherent value, socio-environmental conditions and conscious actions/attitudes as attributes of dignity when caring for a dying patient in the emergency department.

Discussion:

Dying with dignity is a basic objective in end-of-life care and is an ambiguous but relevant concept for physicians and nurses. In line with our theoretical framework, our results highlight care environment, professional actions and socio-family context as attributes of dignity.

Conclusion:

Quality care in the emergency department includes paying attention to the dignity of people in the process of death. The dignity in the care of a dying person in the emergency department is defined by acknowledging the inherent value in each person, socio-environmental conditions and social and individual acceptance of death. Addressing these questions has significant repercussions for health professionals, especially nurses.

Loss of Dignity in End-of-Life Care in the Emergency Department: A Phenomenological Study with Health Professionals

INTRODUCTION

The objective of this study was to explore and describe the experiences of physicians and nurses with regard to loss of dignity in relation to end-of-life care in the emergency department.

METHOD

A phenomenological qualitative study was performed. Two focus groups and 12 individual interviews were conducted with a total of 26 participants, who had attended to patients in the emergency department an average of 14.3 years. An inductive analysis was carried out with the use of ATLAS.ti software to seek emerging themes.

RESULTS

Three themes that helped us understand the phenomenon of the loss of dignity in end-of-life care in the emergency department emerged: (1) "Being exposed in a cold world," with the subthemes "improvising dying person care" and "a lack of space to care for the dying person"; (2) "Being self-critical with professional attitudes," with the subthemes "being aware of undignified actions" and "lack of a palliative culture"; and (3) "Family obstinacy and hospital rescue," with the subthemes "making ill-advised choices" and "avoiding burden."

DISCUSSION

The dignity of people who are taken to the emergency department at the end of their life could be undermined by architectural and organizational characteristics, professionals' attitudes, and decisions made by family members.

[The palliative patient as an emergency patient: A model for decision making in life-threatening situations using 4 case reports]

BACKGROUND

Increasingly more patients reaching our hospitals as an emergency are chronically ill or are in advanced stages of infaust, e.g., malignant, diseases. On the other hand, the treatment options for malignant diseases are improving. In an emergency, a decision must be made between life-sustaining treatment (in the context of a potentially poor prognosis) versus palliation.

DEVELOPMENT OF A DECISION-MAKING MODEL

The current literature about this topic is heterogeneous. The aim of the present article is to present a method using four case reports to decide either for life-sustaining treatment or for palliation with the help of the following: (1) the prognosis of the chronic disease and (2) the association of the acute situation with the chronic disease.

CONCLUSION

This method has an advisory role and cannot be taken as a guideline. Its usefulness can only be proven in practice.

Integrating palliative care in the out-of-hospital setting: four things to jump-start an EMS-palliative care initiative

Emergency medical service (EMS) is frequently called to care for a seriously ill patient with a life-threatening or life-limiting illness. The seriously ill include both the acutely injured patients (for example in mass casualty events) and those who suffer from advanced stages of a chronic disease (for example severe malignant pain). EMS therefore plays an important role in delivering realistic, appropriate, and timely care that is consistent with the patient's wishes and in treating distressing symptoms in those who are seriously ill. The purpose of this article is to; 1) review four case scenarios that relate to palliative care and may be commonly encountered in the out-of-hospital setting and 2) provide a road map by suggesting four things to do to start an EMS-palliative care initiative in order to optimize out-of-hospital care of the seriously ill and increase preparedness of EMS providers in these difficult situations.