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Harhara T, Buhumaid R, Oyoun Alsoud L, Ibrahim H. Palliative care education: a nationwide qualitative study of emergency medicine residency program directors in the United Arab Emirates. Int J Emerg Med 2024; 17:69. [PMID: 38783214 PMCID: PMC11119274 DOI: 10.1186/s12245-024-00643-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Emergency medicine (EM) physicians routinely care for patients with serious life-limiting illnesses. Educating EM residents to have general skills and competencies in palliative medicine is a global priority. The purpose of this study was to describe the current status of palliative and end-of-life education in EM residency programs in the United Arab Emirates (UAE) and to identify barriers and opportunities to inculcating palliative care (PC) instruction into EM training in a non-Western setting. METHODS Using the American College of Emergency Medicine's milestones for Hospice and Palliative Medicine for Emergency Medicine as a question guide, semi-structured interviews were conducted with program directors of all 7 EM residency programs in the UAE from January through July 2023. Qualitative content analysis was conducted to identify recurring themes. RESULTS All program directors agreed that PC knowledge and skills are essential components of training for EM residents but have had variable success in implementing a structured PC curriculum. Six themes emerged, namely the educational curriculum, PC policies and practices, comprehensive PC services, cultural and religious barriers to PC, EM scope of practice, and supporting residents after patient death. CONCLUSION UAE national EM residency curriculum development is evolving with an emphasis on developing a structured PC curriculum. As EM residencies implement policies and programs to improve care for patients and families dealing with serious illness, future studies are needed to assess the impact of these initiatives on patient quality of life and physician well-being.
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Affiliation(s)
- Thana Harhara
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Rasha Buhumaid
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- Department of Emergency Medicine, Rashid Hospital, Dubai Health, Dubai, United Arab Emirates
| | - Leen Oyoun Alsoud
- Department of Medical Sciences, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates
| | - Halah Ibrahim
- Department of Medical Sciences, Khalifa University College of Medicine and Health Sciences, Abu Dhabi, United Arab Emirates.
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Sri-on J, Phumsrisawat J, Rojsaengroeng R. Missed Opportunity to Diagnose Palliative Care Need Among Older Emergency Department Patients in a Middle-Income Country: A Retrospective Study. Open Access Emerg Med 2024; 16:65-73. [PMID: 38659615 PMCID: PMC11041988 DOI: 10.2147/oaem.s449089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/17/2024] [Indexed: 04/26/2024] Open
Abstract
Purpose This study aimed to determine the percentage of missed opportunities (MOs) to identify and treat older adults presenting with palliative care (PC) needs at one emergency department (ED). The secondary objective was to determine the rate of treatment interventions regardless of whether the patients received a PC plan as well as the direct cost of treatment. Patients and Methods In this retrospective study, PC need was determined using broad and narrow criteria. The subjects comprised patients aged 65 or older who had out-of-hospital cardiac arrest and/or died in the ED (Group 1) or within 72 hours after ED disposition (Group 2) over a 3-year period (2016-2018). Overall, 17,414 older adults visited the ED, 60 died in the ED, and 400 died within 72 hours after ED disposition and admitted to in-hospital ward. In total, 200 patients were randomly selected; of these, 15 were excluded. Results Of the remaining 185 patients enrolled, 161/185 (87%) met the PC criteria and 60/161 (37.3%) were missed opportunities for PC planning. Group 1, had thirty patients, and 8 of those 30 (27%) were missed opportunities for PC planning. Group 2, 131/161 (81.4%), died within 72 hours, and there were 52 missed opportunities (39.7%) of ED PC planning. By comorbidity (Group 2), providers considered PC planning most often for cancer patients (PC: 41.8%; missed opportunities: 15.4%; p = 0.001) and there were more missed opportunities for PC planning among those with ischemic heart disease (PC: 19.0%; missed opportunities: 36.5%; p = 0.025). Conclusion Of the older adults who visited the ED, 87% merited palliative care; further, 37% of opportunities for PC planning were missed. Providers considered PC planning most often for cancer patients. Recognizing PC needs and initiating care in the ED can improve end-of-life quality for dying patients.
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Affiliation(s)
- Jiraporn Sri-on
- Geriatric Emergency Medicine Unit, The Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Jesda Phumsrisawat
- The Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Rapeeporn Rojsaengroeng
- The Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Sweeny AL, Alsaba N, Grealish L, Denny K, Lukin B, Broadbent A, Huang YL, Ranse J, Ranse K, May K, Crilly J. The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand. Age Ageing 2024; 53:afae067. [PMID: 38594928 PMCID: PMC11004355 DOI: 10.1093/ageing/afae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people. OBJECTIVES To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere. METHODS We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression. RESULTS From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation. CONCLUSIONS Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.
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Affiliation(s)
- Amy L Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Nemat Alsaba
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Laurie Grealish
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Nursing & Midwifery Education & Research Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Kerina Denny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Department of Intensive Care Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Bill Lukin
- Faculty of Health and Behavioural Sciences, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Andrew Broadbent
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Supportive and Specialist Palliative Care, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Ya-Ling Huang
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health (Nursing), Southern Cross University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Kristen Ranse
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Katya May
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
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Bigelow S, Medzon R, Siegel M, Jin R. Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions. J Palliat Care 2024; 39:3-12. [PMID: 36594209 DOI: 10.1177/08258597221149402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: This study aims to evaluate the potential impact of addressing goals-of-care (GOC) with selected patients in the emergency department (ED), GOC documentation, hospital utilization, and patient satisfaction. Method: This is a single-center, retrospective, and prospective, observational convenience-sample study. ED registered nurses (ED RNs) received standardized GOC conversation training. Their selection criteria included a selection interview, a minimum of 3 years of ED clinical experience, and current employment in the ED. ED RNs used a standardized GOC questionnaire. Patient inclusion criteria included age ≥18 years and one or more of the following: chronic kidney disease ≥ stage III, congestive heart failure with an ejection fraction ≤ 40%, chronic obstructive pulmonary disease with home oxygen use, and/or malignancy with metastasis. GOC conversations were recorded in the electronic medical record (EMR). Physician Orders for Life-Sustaining Treatment (POLST) forms were completed as appropriate. Select individual patient data for the 12 months prior to the conversation were compared with the following 12 months. Results: Over 6 months, 94 of 133 patients who were approached consented to the GOC discussion with the RN. All 94 enrolled patients had their GOC recorded into the EMR. One-third already had a completed POLST form prior to ED arrival. 50% without a POLST on ED arrival left with a completed POLST. Eighty-four patients survived the index visit and 46 patients survived to study completion. Patient satisfaction with the interaction was high: In the cohort who survived past the index visit, 95% rated their experience at 4/5 or 5/5 (Likert scale, 5: strongly agree, 1: strongly disagree). In the survival-to-study completion cohort, 100% rated their experience as 4/5 or 5/5. Subsequent median ED visits decreased by 15% (1.0-4.0 interquartile range). There were no statistically significant changes in hospitalizations (both decreased by 25%, 0-3.0) or intensive care unit admissions (0%, 0-0). Conclusions: An ED RN-led GOC conversation had high patient satisfaction and 100% GOC documentation in the EMR. There was a significant increase in ED POLST form completion. There were no significant changes noted in subsequent hospitalizations, length of hospitalization, or intensive care unit utilization.
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Affiliation(s)
- Suzanne Bigelow
- Emergency Medicine, Providence Regional Medical Center Everett, Everett, WA, USA
- Elson School of Medicine, Washington State University, Spokane, WA, USA
| | - Ron Medzon
- Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Solomont Center for Clinical Simulation and Nursing Education, Boston Medical Center, Boston, Massachusetts, USA
| | - Mari Siegel
- Department of Emergency Medicine, Palliative Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Ruyun Jin
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence Research Network, Portland, OR, USA
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Sausman J, Arif A, Young A, MacArtney J, Bailey C, Rajani J, Burt R. Healthcare professionals' perspectives of the management of people with palliative care needs in the emergency department of a UK hospital. BMC Palliat Care 2023; 22:129. [PMID: 37670312 PMCID: PMC10481573 DOI: 10.1186/s12904-023-01248-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,''REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients. METHODS This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. RESULTS Over the four years (2013-2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. CONCLUSIONS A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.
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Affiliation(s)
- Jane Sausman
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Azra Arif
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Annie Young
- University Hospitals Coventry and Warwickshire, Coventry, UK.
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - John MacArtney
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Cara Bailey
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jaimini Rajani
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Rebecca Burt
- University Hospitals Coventry and Warwickshire, Coventry, UK
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McCallum K. Overcoming the barriers to optimal end of life care in the emergency department. Emerg Nurse 2023:e2170. [PMID: 37667653 DOI: 10.7748/en.2023.e2170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 09/06/2023]
Abstract
The focus of care in the emergency department (ED) is on saving or sustaining life, but some patients admitted to the ED die in the ED. Nurses whose focus is on saving lives may therefore find themselves providing end of life care to patients and their families in a stressful and distressing environment. Providing optimal end of life care involves reflecting on what a good death looks like and how patients can be supported to have a good death. This article describes the barriers to optimal end of life care in the ED and prompts nurses to think about how they can enhance their practice when caring for dying patients and their families.
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Affiliation(s)
- Kay McCallum
- acute oncology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
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Alladin A, Khawand-Azoulai M, Lipman K, Bland S, Ferrari C, Drice J, Van Zuilen MH. Analysis of Student Reflections on "What Matters Most" to Palliative Care Patients: A Narrative Medicine Exercise. J Palliat Med 2023; 26:1115-1120. [PMID: 37083420 DOI: 10.1089/jpm.2023.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Background: Effective communication with ill patients requires practice, yet, the traditional history overlooks patients' personal stories. This information is vital to determining goals of care and facilitates partnership by building trust. Objective: We implemented a narrative medicine exercise for students during their palliative medicine rotation to highlight humanism. Impact was determined through thematic analysis of students' reflections. Design: Students elicited "what matters most" to patients, transcribing this plus a personal reflection. Using an inductive and iterative approach, 100 reflections were analyzed, developing codes then broader themes. Results: Four main themes (Getting to know the patient, Student Reaction, Building-blocks of patient-physician relationship, Student Personal Insights) were identified, with 15 subthemes. Conclusion: The power of uncovering patients' backgrounds and values was demonstrated, reinforcing a palliative medicine approach. Analysis showed a positive impact and the possibility of change to future practice. The intervention was feasible, well received, and encouraged reflection on the physician-patient relationship beyond the medical domain.
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Affiliation(s)
- Amanda Alladin
- Division of Pediatric Critical Care, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mariana Khawand-Azoulai
- Division of Geriatrics and Palliative Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kyra Lipman
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sarah Bland
- Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Corinne Ferrari
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jenny Drice
- Division of Geriatrics and Palliative Medicine, Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
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Ohbe H, Nakajima M, Miyamoto Y, Shibahashi K, Matsui H, Yasunaga H, Sasabuchi Y. 1-year functional outcomes after cardiopulmonary resuscitation for older adults with pre-existing long-term care needs. Age Ageing 2023; 52:7181243. [PMID: 37247400 DOI: 10.1093/ageing/afad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE To investigate the 1-year functional outcomes after cardiopulmonary resuscitation (CPR) in adults aged ≥65 years with pre-existing long-term care needs. METHODS This population-based cohort study was conducted in Tochigi Prefecture, one of 47 prefectures in Japan. We used medical and long-term care administrative databases, which included data on functional and cognitive impairment that were assessed with the nationally standardised care-needs certification system. Among individuals aged ≥65 years registered between June 2014 and February 2018, patients who underwent CPR were identified. The primary outcome was mortality and care needs at 1 year after CPR. The outcome was stratified by pre-existing care needs before CPR based on the total daily estimated care minutes: no care needs, support levels 1 and 2 and care-needs level 1 (estimated care time 25-49 min), care-needs levels 2 and 3 (50-89 min) and care-needs levels 4 and 5 (≥90 min). RESULTS Among 594,092 eligible individuals, 5,086 (0.9%) underwent CPR. The 1-year mortalities after CPR in patients with no care needs, support levels 1 and 2 and care-needs level 1, care-needs levels 2 and 3 and care-needs levels 4 and 5 were 94.6% (n = 2,207/2,332), 96.1% (n = 736/766), 94.5% (n = 930/984) and 95.9% (n = 963/1,004), respectively. Among survivors, most patients had no change in care needs before and at 1 year after CPR. There was no significant association between pre-existing functional and cognitive impairment and 1-year mortality and care needs after adjusting for potential confounders. CONCLUSION Healthcare providers need to discuss poor survival outcomes after CPR with all older adults and their families in shared decision making.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Mikio Nakajima
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
- Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development, Tokyo 192-0364, Japan
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo 150-0013, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Keita Shibahashi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo 130-8575, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo 113-0033, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Tochigi 329-0431, Japan
- Department of Read World Evidence, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
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Ohbe H, Ouchi K, Miyamoto Y, Ishigami Y, Matsui H, Yasunaga H, Sasabuchi Y. One-Year Functional Outcomes After Invasive Mechanical Ventilation for Older Adults With Preexisting Long-Term Care-Needs. Crit Care Med 2023; 51:584-593. [PMID: 36847518 DOI: 10.1097/ccm.0000000000005822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVES To examine 1-year functional outcomes after invasive mechanical ventilation for adults greater than or equal to 65 years with preexisting long-term care-needs. DESIGN We used medical and long-term care administrative databases. The database included data on functional and cognitive impairments that were assessed with the national standardized care-needs certification system and were categorized into seven care-needs levels based on the total daily estimated care minutes. Primary outcome was mortality and care-needs at 1 year after invasive mechanical ventilation. Outcome was stratified by preexisting care-needs at the time of invasive mechanical ventilation: no care-needs, support level 1-2 and care-needs level 1 (estimated care time 25-49 min), care-needs level 2-3 (50-89 min), and care-needs level 4-5 (≥90 min). SETTING A population-based cohort study in Tochigi Prefecture, one of 47 prefectures in Japan. PATIENTS Among people greater than or equal to 65 years old registered between June 2014 and February 2018, patients who received invasive mechanical ventilation were identified. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 593,990 eligible people, 4,198 (0.7%) received invasive mechanical ventilation. The mean age was 81.2 years, and 55.5% were male. The 1-year mortality rates after invasive mechanical ventilation in patients with no care-needs, support level 1-2 and care-needs level 1, care-needs level 2-3, and care-needs level 4-5 at the time of invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1%, respectively. Similarly, those with worsened care-needs were 22.8%, 24.2%, 11.4%, and 1.9%, respectively. CONCLUSIONS Among patients in preexisting care-needs levels 2-5 who received invasive mechanical ventilation, 76.0-79.2% died or had worsened care-needs within 1 year. These findings may aid shared decision-making among patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichiro Ishigami
- Department of Transitional and Palliative Care, Aso Iizuka Hospital, Fukuoka, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Tiah L, Chua MT, Kuan WS, Tan A, Tay E, Yash Pal R, Dong C. Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis. Medicina (B Aires) 2023; 59:medicina59030456. [PMID: 36984457 PMCID: PMC10053832 DOI: 10.3390/medicina59030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
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Affiliation(s)
- Ling Tiah
- Accident & Emergency Department, Changi General Hospital, Singapore Health Services, Singapore 529889, Singapore
- Correspondence:
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Alina Tan
- Department of Anesthesia, National University Hospital, National University of Singapore, Singapore 119074, Singapore
| | - Eileen Tay
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Chaoyan Dong
- Education Office, Sengkang General Hospital, Singapore Health Services, Singapore 554886, Singapore
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Li S, Xie J, Chen Z, Yan J, Zhao Y, Cong Y, Zhao B, Zhang H, Ge H, Ma Q, Shen N. Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China. World J Emerg Med 2023; 14:380-385. [PMID: 37908803 PMCID: PMC10613793 DOI: 10.5847/wjem.j.1920-8642.2023.076] [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: 03/05/2023] [Accepted: 06/20/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies. METHODS This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from "very unimportant" (a score of 1) to "extremely important" (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall's W coefficient was calculated to evaluate the consensus of experts. RESULTS A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall's W coefficient was achieved. CONCLUSION A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.
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Affiliation(s)
- Shu Li
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Jing Xie
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ziyi Chen
- Department of Neurology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Yuliang Zhao
- Department of Nephrology, West China Hospital, West China School of Medicine, Chengdu 610041, China
| | - Yali Cong
- Institute of Medical Humanities, School of Foundational Education, Peking University Health Science Center, Beijing 100191, China
| | - Bin Zhao
- Department of Emergency Medicine, Beijing Jishuitan Hospital, Fourth Medical College of Peking University, Beijing 100035, China
| | - Hua Zhang
- Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, China
| | - Hongxia Ge
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Qingbian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Ning Shen
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
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12
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Stoltenberg MJ, Kennedy M, Rico J, Russell M, Petrillo LA, Engel KG, Kamdar M, Ouchi K, Wang DH, Bernacki RH, Biese K, Aaronson E. Developing a novel integrated geriatric palliative care consultation program for the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12860. [PMCID: PMC9742608 DOI: 10.1002/emp2.12860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022] Open
Abstract
With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life‐limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.
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Affiliation(s)
- Mark J. Stoltenberg
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Janet Rico
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Russell
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kirsten G. Engel
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Mihir Kamdar
- Division of Palliative Care and Geriatric MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Kei Ouchi
- Harvard Medical SchoolBostonMassachusettsUSA,Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA,Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - David H. Wang
- Division of Palliative MedicineScripps HealthSan DiegoCaliforniaUSA
| | - Rachelle H. Bernacki
- Harvard Medical SchoolBostonMassachusettsUSA,Ariadne LabsBrigham and Women's Hospital & Harvard T. H. Chan School of Public HealthBostonMassachusettsUSA,Department of Psychosocial Oncology and Palliative CareDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Kevin Biese
- West Health InstituteLa JollaCaliforniaUSA,Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Emily Aaronson
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
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13
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Bowman JK, Aaronson EL, Petrillo LA, Jacobsen JC. Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID. J Palliat Med 2022; 26:662-666. [PMID: 36378862 DOI: 10.1089/jpm.2022.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.
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Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine and Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura A. Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet C. Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Lund University Institute for Palliative Care, Lund, Sweden
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14
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Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness, Boston, Massachusetts, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason K Bowman
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne G Kuntz
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Karen Jubanyik
- Emergency Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leah E Bright
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric Isaacs
- Emergency Department, Zuckerberg San Francisco General Hospital, University of California at San Francisco, San Francisco, California, USA
| | - Laura A Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lauren LaPointe
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine, Seattle, Washington, USA
| | - Rita Manfredi
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC, USA
| | - Tammie Quest
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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15
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Berger Z, Galasinski D, Scalia P, Dong K, Blunt HB, Elwyn G. The submissive silence of others: Examining definitions of shared decision making. PATIENT EDUCATION AND COUNSELING 2022; 105:1980-1987. [PMID: 34756474 DOI: 10.1016/j.pec.2021.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/01/2021] [Accepted: 10/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Our aim was to use critical discourse analysis (CDA) to examine the most widely cited definitions of shared decision making so that we can evaluate how language is used to position participants. Based on our conceptual understanding, we presumed that shared decision making involves acts of communication where processes are collaborative. METHODS We used a CDA lens to closely examine the phrases, semantics, syntax, implied functions, and the social actions proposed in SDM definition texts. We conducted a systematic search guided by the PRISMA guidelines, to identify the most widely cited definitions of SDM. RESULTS A total of 72 studies met our inclusion criteria. While SDM is not consistently defined, it was striking to find that clinicians are constructed as active whereas patients were viewed to be passive participants. The definitions construct SDM to be a gift that the clinician has the power to offer, and the relationship in the definitions appears asymmetric, in which only one party seems to speak. CONCLUSIONS The SDM definitions examined convey a process characterized by a clinician who speaks, while a patient mostly listens, and is invited to contribute. An alternative definition might be constructed through references to joint activity via sentences in active voice. PRACTICE IMPLICATIONS Clinicians may be influenced by definitions of SDM that reinforce the positionality of active speaker versus passive recipient. Clearer definitions that address the constructs of power and roles may help support the implementation of SDM.
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Affiliation(s)
- Zackary Berger
- Johns Hopkins School of Medicine, Division of General Internal Medicine, and Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA.
| | - Dariusz Galasinski
- Centre for Interdisciplinary Research into Health and Illness, University of Wroclaw, Poland.
| | - Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH 03756, USA.
| | | | - Heather B Blunt
- Biomedical Libraries, Dartmouth College, 37 Dewey Field Road, Hanover, NH 03755, USA.
| | - Glyn Elwyn
- Centre for Interdisciplinary Research into Health and Illness, University of Wroclaw, Poland.
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Gettel CJ, Venkatesh AK, Dowd H, Hwang U, Ferrigno RF, Reid EA, Tinetti ME. A Qualitative Study of "What Matters" to Older Adults in the Emergency Department. West J Emerg Med 2022; 23:579-588. [PMID: 35980413 PMCID: PMC9391017 DOI: 10.5811/westjem.2022.4.56115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/10/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The "4Ms" model - What Matters, Medication, Mentation, and Mobility - is increasingly gaining attention in age-friendly health systems, yet a feasible approach to identifying what matters to older adults in the emergency department (ED) is lacking. Adapting the "What Matters" questions to the ED setting, we sought to describe the concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians. METHODS We conducted 46 dyadic semi-structured interviews of cognitively intact older adults and their treating clinicians. We used the "What Matters" conversation guide to explore patients' 1) concerns and 2) desired outcomes. We then asked analogous questions to each patient's treating clinician regarding the patient's priorities. Interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes. RESULTS Interviews with older adults lasted a mean of three minutes, with a range of 1-8 minutes. Regarding patients' concerns, five themes emerged from older adults: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. Regarding desired outcomes, five priority themes emerged among older adults: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. Responding to what they believed mattered most to older adult patients, ED clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reduction. CONCLUSION This work identifies concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians as well as the feasibility of incorporating the "What Matters" questions within ED clinical practice.
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Affiliation(s)
- Cameron J. Gettel
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
- Yale School of Medicine, Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Arjun K. Venkatesh
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
- Yale School of Medicine, Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Hollie Dowd
- Yale School of Public Health, New Haven, Connecticut
| | - Ula Hwang
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Rockman F. Ferrigno
- Yale New Haven Health – Bridgeport Hospital, Department of Emergency Medicine, Bridgeport, Connecticut
| | - Eleanor A. Reid
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Mary E. Tinetti
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
- Yale School of Public Health, Department of Chronic Disease Epidemiology, New Haven, Connecticut
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17
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Huh JY, Matsuoka Y, Kinoshita H, Ikenoue T, Yamamoto Y, Ariyoshi K. Premorbid Clinical Frailty Score and 30‐day mortality among older adults in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12677. [PMID: 35224550 PMCID: PMC8847731 DOI: 10.1002/emp2.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/03/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives The association between frailty and short‐term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30‐day mortality in this patient population. Methods This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out‐of‐hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients’ chart reviews. The primary outcome was 30‐day mortality, and we examined the association between frailty scored on the CFS and 30‐day mortality using a multivariable logistic regression model with CFS 1–4 as a reference. Results A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30‐day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7–9 was 6.3% (‐3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively. Conclusion The risk of 30‐day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short‐term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.
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Affiliation(s)
- Ji Young Huh
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
| | - Yoshinori Matsuoka
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
- Department of Healthcare Epidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Hiroki Kinoshita
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
| | - Tatsuyoshi Ikenoue
- Department of Human Health Science Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine Kobe City Medical Center General Hospital Kyoto University Kyoto Japan
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Casey MF, Price L, Markwalter D, Bohrmann T, Tsujimoto TM, Lavin K, Hanson LC, Lin FC, Platts-Mills TF. Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program. Am J Hosp Palliat Care 2022; 39:1358-1363. [PMID: 35040696 PMCID: PMC9289079 DOI: 10.1177/10499091211072850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. Design This was an observational pre-/post-interventional study. Setting This study was conducted at a Southeastern U.S. academic ED. Participants 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. Interventions The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. Outcome measures The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. Results There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). Conclusion A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.
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Affiliation(s)
- Martin F Casey
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Laiken Price
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Daniel Markwalter
- Department of Emergency Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Tamy Moraes Tsujimoto
- Department of Biostatistics, 6797University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, NC, USA
| | - Kyle Lavin
- Department of Psychiatry and UNC Palliative Care Program, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and UNC Palliative Care Program, Department of Medicine, 6797University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Feng-Chang Lin
- Department of Biostatistics, 6797University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, NC, USA
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19
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Walker LE, Bellolio MF, Dobler CC, Hargraves IG, Pignolo RJ, Shaw K, Strand JJ, Thorsteinsdottir B, Wilson ME, Hess EP. Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting. MDM Policy Pract 2021; 6:23814683211058082. [PMID: 34796267 PMCID: PMC8593304 DOI: 10.1177/23814683211058082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 10/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work. Design A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these. Results A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary. Limitations Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis. Conclusions Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.
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Affiliation(s)
| | | | - Claudia C Dobler
- Mayo Clinic, Rochester, Minnesota; Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | | | | | | | - Jacob J Strand
- Department of General Internal Medicine Center for Palliative Medicine
| | | | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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20
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Wright R, Lowton K, Hansen BR, Grocott P. Older adult and family caregiver preferences for emergency department based-palliative care: An experience-based co-design study. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2020.100016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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21
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Breyre AM, Bains G, Moore J, Siegel L, Sporer KA. Hospice and Comfort Care Patient Utilization of Emergency Medical Services. J Palliat Med 2021; 25:259-264. [PMID: 34468199 DOI: 10.1089/jpm.2021.0143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.
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Affiliation(s)
- Amelia M Breyre
- Department of Emergency Medicine and University California of San Francisco, San Francisco, California, USA
| | - Gurvijay Bains
- Department of Emergency Medicine, University California of San Francisco, San Francisco, California, USA
| | - Justin Moore
- Department of Emergency Medicine, Alameda Health System, Oakland, California, USA
| | - Lee Siegel
- Alameda County Emergency Medical Services, San Leandro, California, USA
| | - Karl A Sporer
- Alameda County Emergency Medical Services, San Leandro, California, USA
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22
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Lethal means counseling for suicide prevention: Views of emergency department clinicians. Gen Hosp Psychiatry 2021; 71:95-101. [PMID: 33971519 PMCID: PMC8249328 DOI: 10.1016/j.genhosppsych.2021.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Lethal means safety - counseling and guidance about reducing access to home firearms and medications - is recommended for emergency department patients at risk of suicide. Decision aids are tools that can facilitate potentially difficult decisions by incorporating personal preferences and values. The present study evaluates clinician perceptions about the implementation and utility of "Lock to Live," a lethal means safety decision aid. METHOD One-on-one qualitative interviews were conducted with clinicians (n = 15) at three large emergency departments. Interviewees were asked to evaluate the "Lock to Live" decision tool and its potential implementation and utilization in the emergency department. Interviews were recorded and transcribed. Data were coded via thematic analysis; two coders developed a shared codebook iteratively with high interrater reliability. RESULTS Perspectives on the tool fell into three domains: (1) patients (use with patients and families), (2) clinicians, and (3) emergency department system. Interviewees noted that the tool had numerous potential benefits but that its uptake and effectiveness would depend on clinicians' perceptions on its utility, time constraints, and integration into workflow. Addressable concerns related to relationship to other resources, fit within emergency department workflow, and clarification about which emergency department clinician types should use the tool. CONCLUSIONS "Lock to Live" represents a promising new tool for use in suicide prevention as an aid to lethal means counseling. This qualitative study provides insights into the importance of considering the clinical environment when designing and implementing interventions.
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23
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Foglia MB, Cohen JH, Batten A, Alfandre D. An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room. J Palliat Med 2020; 24:873-878. [PMID: 33170071 DOI: 10.1089/jpm.2020.0401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Emergency department (ED) visits are common for older patients with chronic, life-limiting illnesses and may offer a valuable opportunity for clinicians to initiate proactive goals of care conversations (GoCC) to ensure end-of-life care that aligns with the patients' values, goals, and preferences. Objectives: The purpose of this study is to assess whether GoCC are occurring with patients in Department of Veteran Affairs (VA) EDs, to characterize these patients' goals of care and life-sustaining treatment (LST) decisions, and to examine the extent to which palliative or hospice consultations occur following the ED visit. Design: We conducted a cross-sectional retrospective study using health record data. Settings/Subjects: A total of 10,780 patients receiving care in VA, whose first GoCC occurred during an ED visit. Results: Of the patients in the study, approximately half were at least 70 years of age, three-quarters were white, and half had multiple serious disease comorbidities. The percentage of patients who desired cardiopulmonary resuscitation was lower among the highest risk (i.e., of hospitalization and death) patients (64% vs. 51%). The percentage of patients wanting other LSTs (e.g., mechanical ventilation) was higher among the lowest risk patients; and the percentage of patients requesting limits to LSTs was highest among higher risk patients. Eighteen percent of patients had a palliative or hospice care consult within three months of their ED visit. Conclusions: In this study, we verified that GoCC are being initiated in the ED with Veterans at differing stages in their illness trajectory and that higher proportions of higher risk patients preferred to limit LSTs.
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Affiliation(s)
- Mary Beth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jennifer H Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Adam Batten
- Seattle Institute for Biomedical and Clinical Research, Seattle, Washington, USA
| | - David Alfandre
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Population Health, New York University School of Medicine, New York, New York, USA
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24
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Aaronson EL, Petrillo L, Stoltenberg M, Jacobsen J, Wilson E, Bowman J, Ouchi K, Traeger L, Daubman BR, Ritchie CS, Jackson V. The Experience of Emergency Department Providers With Embedded Palliative Care During COVID. J Pain Symptom Manage 2020; 60:e35-e43. [PMID: 32882358 PMCID: PMC7456836 DOI: 10.1016/j.jpainsymman.2020.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Although the importance of palliative care (PC) integration in the emergency department (ED) has long been recognized, few formalized programs have been reported, and none have evaluated the experience of ED clinicians with embedded PC. OBJECTIVES We evaluate the experience of ED clinicians with embedded PC in the ED during the coronavirus disease pandemic. METHODS ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis. RESULTS There were 134 ED clinicians surveyed. About 101 replied (75% response rate). Of those who had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult because of ED volume (5%). About 98% of respondents felt that having PC in the ED was either valuable or very valuable. Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high-quality goal-concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED. CONCLUSION ED clinicians' perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Laura Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Stoltenberg
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erica Wilson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Andersen SK, Montgomery CL, Bagshaw SM. Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission. J Crit Care 2020; 60:279-284. [PMID: 32942163 DOI: 10.1016/j.jcrc.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe patients who die within 24 h of ICU admission in order to better optimize care delivery. METHODS This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression. RESULTS Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6). CONCLUSION Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.
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Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
| | - Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada; Alberta Health Services Critical Care Strategic Clinical Network, Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
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26
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Brooten JK, Buckenheimer AS, Hallmark JK, Grey CR, Cline DM, Breznau CJ, McQueen TS, Harris ZJ, Welsh D, Williamson JD, Gabbard JL. Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions. West J Emerg Med 2020; 21:935-942. [PMID: 32726267 PMCID: PMC7390558 DOI: 10.5811/westjem.2020.5.46067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality. Methods This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults. Results We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%. Conclusion The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.
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Affiliation(s)
- Justin K Brooten
- Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Alyssa S Buckenheimer
- Wake Forest School of Medicine, Department of Internal Medicine, Section on General Internal Medicine, Winston-Salem, North Carolina
| | - Joy K Hallmark
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Carl R Grey
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - David M Cline
- Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina
| | - Candace J Breznau
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Tyler S McQueen
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Zvi J Harris
- Wake Forest Graduate School of Arts and Science, Department of Biomedical Science, Winston-Salem, North Carolina
| | - David Welsh
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeff D Williamson
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Center for Health Care Innovation, Department of Internal Medicine, Winston-Salem, North Carolina
| | - Jennifer L Gabbard
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Center for Health Care Innovation, Department of Internal Medicine, Winston-Salem, North Carolina
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27
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Abstract
Whether because of a cultural pattern or personal preference, palliative care clinicians encounter persons approaching the end of life who wish to limit or forego prognostic information relating to their situation. This scenario has received attention in a recent motion picture as well as a newly available advance directive modification—the Prognosis Declaration form. The ordinary expectation for end-of-life shared decision-making with a capable person is clinician disclosure of the best effort at prognostic assessment. The optimal match between the expressed values, goals, and preferences of the person with available clinician expertise is hopefully achieved. For the clinician, a person’s choice to modify information disclosure and participation in shared decision-making represents a significant challenge of balancing key ethical principles of intervention with tolerance and compassion for these different preferences. Attention to communication strategies that elicit and appropriately reassess individual information and decision-making wishes, flexibility in information disclosure patterns with capable persons and their representatives, and recognition that a respect for autonomy includes the choice to opt out can approach this challenge while providing compassionate and ethical end-of-life care.
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Affiliation(s)
- Robert F. Johnson
- Kirkhof College of Nursing, Grand Valley State University, Grand Rapids, MI, USA
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28
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Yang C, Yang TT, Tsou YJ, Lin MH, Fan JS, Huang HH, Tsai MC, Yen DHT. Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit. J Chin Med Assoc 2020; 83:500-506. [PMID: 32168079 DOI: 10.1097/jcma.0000000000000297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU). METHODS We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization. RESULTS A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05). CONCLUSION Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.
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Affiliation(s)
- Che Yang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tsu-Te Yang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yu-Ju Tsou
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Hui Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ming-Che Tsai
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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29
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Wilson JG, English DP, Owyang CG, Chimelski EA, Grudzen CR, Wong HN, Aslakson RA. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage 2020; 59:372-383.e1. [PMID: 31586580 DOI: 10.1016/j.jpainsymman.2019.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT There is growing interest in providing palliative care (PC) in the emergency department (ED), but relatively little is known about the efficacy of ED-based PC interventions. A 2016 systematic review on this topic found no evidence that ED-based PC interventions affect patient outcomes or health care utilization, but new research has emerged since the publication of that review. OBJECTIVES This systematic review provides a concise summary of current literature addressing the impact of ED-based PC interventions on patient-reported or family reported outcomes, health care utilization, and survival. METHODS We searched PubMed, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature from inception until September 1, 2018 and reviewed references. Eligible articles evaluated the effects of PC interventions in the ED on patient-reported or family reported outcomes, health care utilization, or survival. RESULTS We screened 3091 abstracts and 98 full-text articles with 13 articles selected for final inclusion. Two articles reported the results of a single randomized controlled trial, whereas the remaining 11 studies were descriptive or quasi-experimental cohort studies. More than half of the included articles were published after the previous systematic review on this topic. Populations studied included older adults, patients with advanced malignancy, and ED patients screening positive for unmet PC needs. Most interventions involved referral to hospice or PC or PC provided directly in the ED. Compared with usual care, ED-PC interventions improved quality of life, although this improvement was not observed when comparing ED-PC to inpatient PC. ED-PC interventions expedited PC consultation; most studies reported a concomitant reduction in hospital length of stay and increase in hospice utilization, but some data were conflicting. Short-term mortality rates were high across all studies, but ED-PC interventions did not decrease survival time compared with usual care. CONCLUSION Existing data support that PC in the ED is feasible, may improve quality of life, and does not appear to affect survival.
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Affiliation(s)
- Jennifer G Wilson
- Department of Emergency Medicine, Stanford University, Stanford, California, USA.
| | - Diana P English
- Division of Hospice and Palliative Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Clark G Owyang
- Division of Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Erica A Chimelski
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA; Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Divisions of Critical Care and Hospice and Palliative Medicine, Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA
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30
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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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Conflict Experienced by Nurses Providing End-of-life Care in Emergency Departments in Japan. J Trauma Nurs 2019; 26:154-163. [PMID: 31483774 DOI: 10.1097/jtn.0000000000000441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Saving lives is the first priority in emergency departments. However, it is important to provide end-of-life care (EOLC) for patients and their families in these departments when the patient's life cannot be saved. Existing work reporting the obstacles and difficulties of nursing practice has found that the perceptions of nurses who provide EOLC include distress and conflict. The primary aims of this study were (i) to clarify the structure of the conflict experienced by nurses providing EOLC in emergency departments and (ii) to explore factors influencing this experience of conflict. A questionnaire survey was conducted among nurses working in emergency departments in Japan. The participants were sampled using a random sampling design. In total, 290 (55.3%) nurses responded to the survey and 288 (55.0%) responses were usable for the analysis. Seven components comprising 31 items were identified: (1) conflict about ability to practice EOLC; (2) conflict about relationships with the medical team; (3) conflict about the environment for EOLC; (4) conflict about decision making; (5) conflict about family nursing; (6) conflict about patients' pain; and (7) conflict about medical limitations. The nurses' individual backgrounds and support systems were found to influence their experience of conflict. To support nurses providing EOLC in emergency departments, we need to understand the conflict they experience, including how their backgrounds affect this experience, and construct a system that incorporates support from the specialized field of EOLC.
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The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department. Ann Emerg Med 2019; 75:171-180. [PMID: 31248675 DOI: 10.1016/j.annemergmed.2019.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
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Hanning J, Walker KJ, Horrigan D, Levinson M, Mills A. Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review. Emerg Med Australas 2019; 31:525-532. [DOI: 10.1111/1742-6723.13303] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/26/2019] [Accepted: 03/31/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer Hanning
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Melbourne Medical SchoolThe University of Melbourne Melbourne Victoria Australia
| | - Katherine J Walker
- Emergency DepartmentCabrini Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | | | | | - Amber Mills
- Monash University Melbourne Victoria Australia
- Cabrini Institute Melbourne Victoria Australia
- Bolton Clarke Research Institute Melbourne Victoria Australia
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Bell D, Ruttenberg MB, Chai E. Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department. Clin Geriatr Med 2019; 34:453-467. [PMID: 30031427 DOI: 10.1016/j.cger.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.
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Affiliation(s)
- Daniel Bell
- Department of Emergency Medicine, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
| | - Margaret Brungraber Ruttenberg
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Emily Chai
- Geriatrics and Palliative Medicine Inpatient Services, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1970, New York, NY 10029, USA
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Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities. Ann Emerg Med 2019; 74:276-284. [PMID: 30770207 DOI: 10.1016/j.annemergmed.2019.01.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/20/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
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.
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Robertson AC, Fowler LC, Niconchuk J, Kreger M, Rickerson E, Sadovnikoff N, Hepner DL, Bader AM, Mcevoy MD, Urman RD. Application of Kern's 6-Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions. THE JOURNAL OF EDUCATION IN PERIOPERATIVE MEDICINE : JEPM 2019; 21:E634. [PMID: 31406705 PMCID: PMC6685461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking. METHODS Using Kern's 6-step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy. RESULTS Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective-structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence-based best practices content covering professional guidelines, current literature, shared decision-making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions. CONCLUSION Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision-making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.
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Ortega-Galán ÁM, Ruiz-Fernández MD, Ortiz-Amo R, Cabrera-Troya J, Carmona-Rega IM, Ibáñez-Masero O. Care received at the end of life in emergency services from the perspective of caregivers: A qualitative study. ENFERMERIA CLINICA 2018; 29:10-17. [PMID: 30522908 DOI: 10.1016/j.enfcli.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/22/2018] [Accepted: 09/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To discover the experiences of end-of-life patients attended by the emergency services, through the discourse of the family caregivers who accompanied the family member in this care transit. METHOD A qualitative approach study, based on the paradigm of hermeneutical phenomenology. In total, 81 family caregivers participated. The techniques used were the in-depth interview and the discussion group, with a total of 5 discussion groups and 41 interviews. The period of data collection was carried out between January 2013 and June 2014. RESULTS In the network of discourses obtained with respect to "Urgent Care", all the codes were grouped in relation to a single argumentative line: deficiencies in urgent care. Among them, we found different dimensions that are established depending on the different times of care, or the different determinant aspects of these deficiencies: disorganization of the care received, lack of experience of the professionals in emergencies, application of general protocols in the emergency services, inadequate care in the treatment received, delays in emergency care. CONCLUSIONS In general, we highlight the dissatisfaction of the family members with respect to the care received from the emergency services. The needs of these types of situation are not covered from these services and are of low quality. Therefore, it is necessary to reorient the care protocols for these patients.
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Affiliation(s)
| | - M Dolores Ruiz-Fernández
- Departamento de Enfermería, Fisioterapia y Medicina, Universidad de Almería, Almería, España. Distrito Sanitario Almería, Servicio Andaluz de Salud, Almería, España; Distrito Sanitario Almería, Servicio Andaluz de Salud, Almería, España.
| | - Rocío Ortiz-Amo
- Departamento de Enfermería, Fisioterapia y Medicina, Universidad de Almería, Almería, España. Distrito Sanitario Almería, Servicio Andaluz de Salud, Almería, España
| | | | | | - Olivia Ibáñez-Masero
- Unidad de Cuidados Intensivos, Complejo Hospitalario Universitario de Huelva, Huelva, España
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Missed Opportunities: Integrating Palliative Care into the Emergency Department for Older Adults Presenting as Level I Triage Priority from Long-Term Care Facilities. J Emerg Med 2018; 56:145-152. [PMID: 30527561 DOI: 10.1016/j.jemermed.2018.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/29/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care. OBJECTIVE Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement. METHODS We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed. RESULTS Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%). CONCLUSIONS Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED.
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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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40
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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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Rowhani M, Iglseder B. Polypharmacy in palliative care-COPD and multimorbidity : A case report. Wien Med Wochenschr 2018; 168:177-183. [PMID: 29651743 DOI: 10.1007/s10354-018-0633-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 03/15/2018] [Indexed: 10/17/2022]
Abstract
This is the case report of an 80-year-old woman with advanced chronic obstructive pulmonary disease (COPD), multimorbidity and frailty. Despite regular critical re-evaluation of on-going medication, a significant reduction of prescribed medication was not achieved up until the patient's terminal phase, and this may have contributed to several episodes of delirium. It was particularly difficult to reduce the number of prescribed drugs due to cardiovascular, endocrinologic, orthopaedic, neurologic, psychiatric and pulmonary comorbidities. Probable drug-drug interactions and side effects were repeatedly observed. This case report aims to describe a dilemma frequently encountered in the care of patients with progressed pulmonary disease in the context of frailty and multimorbidity.
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Affiliation(s)
- Marcel Rowhani
- Franziskus Spital, Nikolsdorfergasse 32, 1050, Vienna, Austria.
| | - Bernhard Iglseder
- Department of Geriatric Medicine, Salzburger Landeskliniken Betriebs-GesmbH, Christian-Doppler-Klinik, Paracelsus Medical University Salzburg Austria, Salzburg, Austria
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Ouchi K, Jambaulikar GD, Hohmann S, George NR, Aaronson EL, Sudore R, Schonberg MA, Tulsky JA, Schuur JD, Pallin DJ. Prognosis After Emergency Department Intubation to Inform Shared Decision-Making. J Am Geriatr Soc 2018. [PMID: 29542117 DOI: 10.1111/jgs.15361] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To inform the shared decision-making process between clinicians and older adults and their surrogates regarding emergency intubation. DESIGN Retrospective cohort study. SETTING Multicenter, emergency department (ED)-based cohort. PARTICIPANTS Adults aged 65 and older intubated in the ED from 2008 to 2015 from 262 hospitals across the United States (>95% of U.S. nonprofit academic medical centers). MEASUREMENTS Our primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds of death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographic region. RESULTS We identified 41,463 ED intubation encounters and included 35,036 in the final analysis. Sixty-four percent were in non-Hispanic whites and 54% in women. Overall in-hospital mortality was 33% (95% confidence interval (CI)=34-35%). Twenty-four percent (95% CI=24-25%) of subjects were discharged to home, and 41% (95% CI=40-42%) were discharged to a location other than home. Mortality was 29% (95% CI=28-29%) for individuals aged 65 to 74, 34% (95% CI=33-35%) for those aged 75 to 79, 40% (95% CI=39-41%) for those aged 80 to 84, 43% (95% CI=41-44%) for those aged 85 to 89, and 50% (95% CI=48-51%) for those aged 90 and older. CONCLUSION After emergency intubation, 33% percent of older adults die during the index hospitalization. Only 24% of survivors are discharged to home. Simple, graphic representations of this information, in combination with an experienced clinician's overall clinical assessment, will support shared decision-making regarding unplanned intubation.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
| | | | - Samuel Hohmann
- Center for Advanced Analytics, Vizient, Irving, Texas.,Department of Health Systems Management, Rush University, Chicago, Illinois
| | - Naomi R George
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca Sudore
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Wright RJ, Lowton K, Robert G, Grudzen CR, Grocott P. Emergency department staff priorities for improving palliative care provision for older people: A qualitative study. Palliat Med 2018; 32:417-425. [PMID: 28429643 DOI: 10.1177/0269216317705789] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Rebecca J Wright
- 1 Florence Nightingale Faculty of Nursing & Midwifery, King's College London, London, UK.,2 Ronald O. Perelman Department of Emergency Medicine, School of Medicine, New York University, New York, NY, USA
| | - Karen Lowton
- 3 Department of Sociology, University of Sussex, Brighton, UK
| | - Glenn Robert
- 1 Florence Nightingale Faculty of Nursing & Midwifery, King's College London, London, UK
| | - Corita R Grudzen
- 2 Ronald O. Perelman Department of Emergency Medicine, School of Medicine, New York University, New York, NY, USA
| | - Patricia Grocott
- 1 Florence Nightingale Faculty of Nursing & Midwifery, King's College London, London, UK
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Cotogni P, Saini A, De Luca A. In-Hospital Palliative Care: Should We Need to Reconsider What Role Hospitals Should Have in Patients with End-Stage Disease or Advanced Cancer? J Clin Med 2018; 7:jcm7020018. [PMID: 29385757 PMCID: PMC5852434 DOI: 10.3390/jcm7020018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/08/2018] [Accepted: 01/13/2018] [Indexed: 12/25/2022] Open
Abstract
Traditionally, palliative care (PC) systems focused on the needs of advanced cancer patients, but most patients needing PC have end-stage organ diseases. Similarly, PC models focus on the needs of patients in hospices or at home; however, in most cases PC is provided in acute hospitals. Indeed, the symptom burden that these patients experience in the last year of life frequently forces them to seek care in emergency departments. The majority of them are admitted to the hospital and many die. This issue poses important concerns. Despite the efforts of attending healthcare professionals, in-hospital patients do not receive optimal care near the end-of-life. Also, evidence is emerging that delay in identifying patients needing PC have a detrimental impact on their quality of life (QoL). Therefore, there is an urgent need to identify, early and properly, these patients among those hospitalized. Several trials reported the efficacy of PC in improving the QoL in these patients. Each hospital should ensure that a multidisciplinary PC team is available to support attending physicians to achieve the best QoL for both PC patients and their families. This review discusses the role and the impact of in-hospital PC in patients with end-stage disease or advanced cancer.
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Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
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Moman RN, Loprinzi Brauer CE, Kelsey KM, Havyer RD, Lohse CM, Bellolio MF. PREDICTing Mortality in the Emergency Department: External Validation and Derivation of a Clinical Prediction Tool. Acad Emerg Med 2017; 24:822-831. [PMID: 28401622 DOI: 10.1111/acem.13197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND The Choosing Wisely campaign has called for better engagement of palliative and hospice care services for patients in the emergency department (ED). PREDICT is a clinical prediction tool that was derived in an Australian ED cohort. It assesses a patient's risk of mortality at 1 year to select those who would benefit from advanced care planning. Such goals-of-care discussion can improve patients' ability to communicate what they want out of their healthcare and, in cases of end of life, potentially reduce the number of futile interventions. Using a cutoff of 13 points, PREDICT had a reported 95.3% specificity and 53.9% sensitivity for 1-year mortality. We externally validated PREDICT and derived a simpler modified PREDICT tool to systematically identify high-risk patients eligible for goals-of-care discussions and palliative care consultation in the ED. METHODS This was an observational cohort study of a random sample of 927 patients aged 55+ seen in the ED in 2014. We identified advance healthcare directives (AHDs) on file. We summarized diagnostic accuracy of the clinical tool to predict 1-year mortality using sensitivity, specificity, and area under the curve (AUC). We refined PREDICT using multivariable modeling. We followed reporting guidelines including STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) for cohort studies and Standards for Reporting of Diagnostic Accuracy (STARD). RESULTS A total of 927 patients were included: 55.0% were male, 63 (7.0%) were nursing home residents, 389 (42.0%) patients had an AHD in their medical record at the time of ED visit, and 245 (26.4%) were deceased at 1 year. Of the 780 patients with PREDICT scores < 13, a total of 164 (21.0%; 95% confidence interval [CI] = 18.3-24.1) were deceased at 1 year, and of the 147 patients with PREDICT scores ≥ 13, a total of 81 (55.1%; 95% CI = 46.7-63.2) were deceased at 1 year. The AUC of the PREDICT score was 0.717 (95% CI = 0.680-0.754), sensitivity was 33.1% (95% CI = 27.3-39.4), and specificity was 90.3% (95% CI = 87.8-92.4) to predict 1-year mortality. The modified PREDICT tool resulted in an AUC of 0.709 (95% CI = 0.671-0.747). We decided to select this model as the preferred model, as the variable of intensive care unit (ICU) admission with multiorgan failure can be difficult to assess in the ED and may delay advanced care planning. Reweighting the score did not improve fit or the AUC, so points assigned to each variable were not adjusted. CONCLUSION PREDICT is an easy tool to administer to be able to identify patients who are at high risk of 1-year mortality and who could benefit from AHDs, goals-of-care discussion, and when appropriate in the context of an end-of-life setting, palliative medicine consultation. External validation of PREDICT was successful in our population. We simplified PREDICT and derived a new tool, the modified PREDICT minus ICU tool, without significantly altering the sensitivity, specificity, and AUC for death at 1 year. The next steps include external validation of the newly derived rule and prospective implementation.
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Affiliation(s)
- Rajat N. Moman
- Department of Emergency Medicine; Rochester MN
- Mayo Clinic, and the Mayo Clinic School of Medicine; Rochester MN
| | | | - Katherine M. Kelsey
- Department of Emergency Medicine; Rochester MN
- Mayo Clinic, and the Mayo Clinic School of Medicine; Rochester MN
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Melnick ER, Probst MA, Schoenfeld E, Collins SP, Breslin M, Walsh C, Kuppermann N, Dunn P, Abella BS, Boatright D, Hess EP. Development and Testing of Shared Decision Making Interventions for Use in Emergency Care: A Research Agenda. Acad Emerg Med 2016; 23:1346-1353. [PMID: 27457137 DOI: 10.1111/acem.13045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/30/2016] [Accepted: 07/07/2016] [Indexed: 11/30/2022]
Abstract
Decision aids are evidenced-based tools designed to increase patient understanding of medical options and possible outcomes, facilitate conversation between patients and clinicians, and improve patient engagement. Decision aids have been used for shared decision making (SDM) interventions outside of the ED setting for more than a decade. Their use in the ED has only recently begun to be studied. This article provides background on this topic and the conclusions of the 2016 Academic Emergency Medicine consensus conference SDM in practice work group regarding "Shared Decision Making in the Emergency Department: Development of a Policy-Relevant, Patient-Centered Research Agenda." The goal was to determine a prioritized research agenda for the development and testing of SDM interventions for use in emergency care that was most important to patients, clinicians, caregivers, and other key stakeholders. Using the nominal group technique, the consensus working group proposed prioritized research questions in six key domains: 1) content (i.e., clinical scenario or decision area), 2) level of evidence available, 3) tool design strategies, 4) risk communication, 5) stakeholders, and 6) outcomes.
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Affiliation(s)
- Edward R. Melnick
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Marc A. Probst
- Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | | | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | | | | | - Nathan Kuppermann
- Department of Emergency Medicine; University of California; Davis School of Medicine; Sacramento CA
| | - Pat Dunn
- Patient and Healthcare Innovations and Center for Health Technology and Innovation; American Heart Association; Dallas TX
| | - Benjamin S. Abella
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
| | - Dowin Boatright
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
- Robert Wood Johnson Clinical Scholar Program; Yale University School of Medicine; New Haven CT
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
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