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Wechsler AH, Sandoval M, Viets-Upchurch J, Cruz Carreras M, Page VD, Elsayem A, Qdaisat A, Yeung SCJ. Prior Advanced Care Planning and Outcomes of Cardiopulmonary Resuscitation in the Emergency Department of a Comprehensive Cancer Center. Cancers (Basel) 2024; 16:2835. [PMID: 39199606 PMCID: PMC11353090 DOI: 10.3390/cancers16162835] [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: 06/25/2024] [Revised: 08/09/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024] Open
Abstract
Cardiopulmonary resuscitation (CPR) outcomes vary for patients with cancer. Here, we characterized cancer patients who underwent CPR in the emergency department (ED), their outcomes, and the effects of advanced care planning (ACP). The hospital databases and electronic medical records of cancer patients at a comprehensive cancer center who underwent CPR in the ED from 6 March 2016 to 31 December 2022 were reviewed for patient characteristics, return of spontaneous circulation (ROSC), conversion to do-not-resuscitate (DNR) status afterward, hospital and intensive care unit (ICU) length of stay, mortality, cost of hospitalization, and prior GOC discussions. CPR occurred in 0.05% of all ED visits. Of the 100 included patients, 67 patients achieved ROSC, with 15% surviving to hospital discharge. The median survival was 26 h, and the 30-day mortality rate was 89%. Patients with and without prior ACP had no significant differences in demographics, metastatic involvement, achievement of ROSC, or in-hospital mortality, but patients with ACP were more likely to change their code status to DNR and had shorter stays in the ICU or hospital. In conclusion, few cancer patients undergo CPR in the ED. Whether this results from an increase in terminally ill patients choosing DNR status requires further study. ACP was associated with increased conversion to DNR after resuscitation and decreased hospital or ICU stays without an increase in overall mortality.
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Affiliation(s)
- Adriana H. Wechsler
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.S.); (J.V.-U.); (M.C.C.); (V.D.P.); (A.E.); (A.Q.); (S.-C.J.Y.)
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Efstathiou N, Guo P, Walker W, MacArtney JI, Bailey C. Setting Regional Priorities for Palliative and End-of-Life Care Research Using a Delphi Technique Approach. J Palliat Care 2024:8258597241264455. [PMID: 39056368 DOI: 10.1177/08258597241264455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Identifying research priorities is very important for palliative and end-of-life care to ensure research is focused on evidence gaps. This project aimed to identify and prioritise palliative and end-of-life care research areas within the West Midlands region in United Kingdom (UK). METHODS A modified Delphi technique approach was used with palliative care stakeholders. The first round was item generation via rapid interviews. Data were analysed using content analysis and all the items were grouped into main categories. For round two, an online survey was conducted to present all the items from round one, and stakeholders were asked to rate the priority of items on a Likert-type scale (1 = not a priority to 7 = essential priority). Items that achieved consensus in round two were presented to the third round, where stakeholders ranked them in descending order. RESULTS We completed and analysed 56 rapid interviews which resulted in 158 research items under 15 categories. The research items were rated by 30 stakeholders and seven items which reached consensus were subsequently ranked in order by 45 stakeholders. The highest ranked item was 'Integrated care systems to prevent crisis', followed by three research items related to 'equity' in palliative care. CONCLUSIONS Our research priorities, although unique for our region, mirror previously research priorities from other regions and countries. This suggests issues of integration and equity in palliative and end-of-life care remain unresolved, despite ongoing initiatives and research to address these issues.
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Affiliation(s)
- Nikolaos Efstathiou
- University of Birmingham, College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing and Midwifery, Birmingham, UK
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Ping Guo
- University of Birmingham, College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing and Midwifery, Birmingham, UK
| | - Wendy Walker
- The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - John I MacArtney
- Unit of Academic Primary Care, University of Warwick, Warwick, UK
| | - Cara Bailey
- University of Birmingham, College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing and Midwifery, Birmingham, UK
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3
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Sriranganathan N, Morris D, Campbell L, Hift R. Palliative care in the emergency department: An observational study of doctors in KwaZulu-Natal. S Afr Fam Pract (2004) 2024; 66:e1-e6. [PMID: 38708747 PMCID: PMC11079381 DOI: 10.4102/safp.v66i1.5860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND The World Health Organization advocates the early, appropriate provision of palliative care (PC) to patients throughout the life course. Patient consultations to the emergency department (ED) have been recognised as opportunities to initiate or optimise their PC needs. This study aimed to assess the knowledge of and attitudes towards PC among doctors at emergency physician staffed EDs in KwaZulu-Natal, South Africa. METHODS A cross-sectional survey was conducted between November 2021 and February 2022 for doctors employed out at emergency physician staffed EDs in KwaZulu-Natal, South Africa, using the validated Palliative Care Attitude and Knowledge questionnaire. The variables assessed were the self-rated and basic knowledge and attitudes towards core domains of PC. Ordinal data were compared using the t-test or ANOVA as appropriate, using MedCalc® Statistical Software version 22.009. RESULTS Of the 39 participants, the scores for the knowledge questions showed that 15.3% participants had good knowledge, 53.8% had fair knowledge and 30.7% had poor knowledge. Participants had either favourable (58.8%) or an uncertain (41.0%) attitude towards PC. No correlation was seen between the knowledge and attitudes scores (Spearman's rho = 0.13, 95% CI -0.19 to 0.43, p = 0.43). CONCLUSION There appears to be a deficit in knowledge of PC among doctors in the ED and a need for in-service training in PC for emergency care physicians.Contribution: This study provides new knowledge around PC practices at EDs in KwaZulu-Natal, South Africa.
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Affiliation(s)
- Nagaleswari Sriranganathan
- Department of Emergency Medicine, Division of Emergency Medicine, School of Clinical Medicine, University of KwaZulu-Natal, Durban.
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Wang YJ, Hsu CY, Yen AMF, Chen HH, Lai CC. Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department. BMC Palliat Care 2024; 23:51. [PMID: 38389106 PMCID: PMC10885365 DOI: 10.1186/s12904-024-01391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired. METHODS We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year. RESULTS A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic. CONCLUSIONS The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.
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Affiliation(s)
- Yu-Jing Wang
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
- Medical Department, Daichung Hospital, Miaoli, Taiwan
- Taiwan Association of Medical Screening, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan.
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan.
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]. Med Klin Intensivmed Notfmed 2023; 118:14-38. [PMID: 37285027 PMCID: PMC10244869 DOI: 10.1007/s00063-023-01016-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität und Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, 90471, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
| | - Bernd Schucher
- Abteilung Pneumologie, LungenClinic Großhansdorf, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Universitätsmedizin Essen Ruhrlandklinik, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Universität zu Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Universitätsklinikum, Universitäts-Notfallzentrum, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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Krebs LD, Hill N, Kirkland SW, Villa-Roel C, Elwi A, O'Neill B, Duggan S, Brisebois A, Rowe BH. "Tough Medicine": Qualitative analysis of clinician experiences providing palliative care in emergency departments. Int Emerg Nurs 2023; 69:101294. [PMID: 37167856 DOI: 10.1016/j.ienj.2023.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/14/2023] [Accepted: 04/04/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Lynette D Krebs
- Department of Emergency Medicine, University of Alberta, Alberta, Canada
| | - Nicole Hill
- Department of Emergency Medicine, University of Alberta, Alberta, Canada; Department of Sociology, University of Alberta, Alberta, Canada
| | - Scott W Kirkland
- Department of Emergency Medicine, University of Alberta, Alberta, Canada
| | | | - Adam Elwi
- Alberta Health Services, Alberta, Canada
| | | | - Shelley Duggan
- Grey Nuns Hospital, Covenant Health Department of Medicine and Palliative Care, Alberta, Canada; Department of Medicine, University of Alberta, Alberta, Canada
| | - Amanda Brisebois
- Grey Nuns Hospital, Covenant Health Department of Medicine and Palliative Care, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Alberta, Canada; Department of Medicine, University of Alberta, Alberta, Canada; School of Public Health, University of Alberta, Alberta, Canada.
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7
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Koyavatin S, Liu SW, Sri-On J. A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients. BMC Palliat Care 2023; 22:81. [PMID: 37370078 DOI: 10.1186/s12904-023-01205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED). METHODS This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests. RESULTS A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77. CONCLUSIONS Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.
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Affiliation(s)
- Siripan Koyavatin
- Emergency department, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Shan Woo Liu
- Emergency department, Massachusetts General Hospital, Boston, USA
| | - Jiraporn Sri-On
- Emergency department, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
- Geriatric Emergency Medicine Unit. The Department of Emergency Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen road. Dusit, Bangkok, 10130, Thailand.
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8
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Gage CH, Stander C, Gwyther L, Stassen W. Emergency medical services and palliative care: a scoping review. BMJ Open 2023; 13:e071116. [PMID: 36927584 PMCID: PMC10030966 DOI: 10.1136/bmjopen-2022-071116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES The aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present? DESIGN A scoping review of literature was performed with an a priori search strategy. DATA SOURCES MEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Empirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. RESULTS In total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS' palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration. CONCLUSION EMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.
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Affiliation(s)
- Caleb Hanson Gage
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Charnelle Stander
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Liz Gwyther
- Division of Interdisciplinary Palliative Care and Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
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9
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Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 PMCID: PMC11298868 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
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Affiliation(s)
- Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness, Boston, Massachusetts, USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center, New York, New York, USA
| | - Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason K. Bowman
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne G. Kuntz
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Karen Jubanyik
- Emergency Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leah E. Bright
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric Isaacs
- Emergency Department, Zuckerberg San Francisco General Hospital, University of California at San Francisco, San Francisco, California, USA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lauren LaPointe
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine, Seattle, Washington, USA
| | - Rita Manfredi
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC, USA
| | - Tammie Quest
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Aquino J, Crilly J, Ranse K. The end-of-life care practices of emergency care nurses and the factors that influence these practices: An integrative review. Int Emerg Nurs 2022; 63:101168. [DOI: 10.1016/j.ienj.2022.101168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/14/2022] [Accepted: 03/15/2022] [Indexed: 12/01/2022]
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Nalugya LG, Harborne D, Reid E. Factors affecting initiation of palliative care in a Ugandan Emergency Department. Afr J Emerg Med 2021; 11:442-446. [PMID: 34765429 PMCID: PMC8568603 DOI: 10.1016/j.afjem.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/30/2021] [Accepted: 06/04/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The Emergency Department (ED) of Mbarara Regional Referral Hospital serves a largely rural population of 4 million people in western Uganda. Here, ED patients with incurable illness often have prolonged stays. Palliative care (PC) is a low-cost intervention that focuses on alleviating pain and suffering for patients with incurable disease, while improving satisfaction with care and optimizing healthcare utilization. This is especially important in low resource settings. A prior needs assessment in our ED revealed that 50% of patients have PC needs. The ED is an optimal location to initiate PC, yet this rarely happens. There is a great need to identify factors affecting initiation of ED PC in our resource-limited setting. Methods A semi-structured questionnaire and chart review was conducted from March to August 2020. Patients admitted from the ED were assessed for PC needs. Those who met criteria were approached for inclusion and flagged for initiation of PC. The follow-up period was 7 days. Results Sixty two percent of those subjects flagged for initiation of PC received it. By day seven, 36.1 of the study population had died. ED initiation of PC varied significantly by diagnosis, with cancer patients more likely to receive PC (p = 0.0097). Conclusion Important barriers to PC initiation were identified in our Ugandan ED, related to diagnosis. These barriers could be overcome by improving awareness of PC amongst patients and providers alike and implementing a PC screening tool for all admissions. Future research is needed to identify other barriers, as well as strategies for improved hospital-wide uptake of PC in this resource-limited setting.
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12
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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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13
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Aquino J, Crilly J, Ranse K. End-of-life care in emergency departments: A national cross-sectional survey of emergency care nurses. Australas Emerg Care 2021; 25:161-166. [PMID: 34801474 DOI: 10.1016/j.auec.2021.09.001] [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: 05/18/2021] [Revised: 08/16/2021] [Accepted: 09/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND An ageing population and increasing chronicity of illness will likely contribute to increasing presentations to the emergency department (ED) by patients at the end-of-life (EOL). This study aimed to identify the self-reported EOL care practices of emergency care nurses and the factors influencing EOL care. METHODS An online survey was distributed to Australian emergency care nurses in August, 2020. Statistical analyses were undertaken to identify the most frequently undertaken EOL practices and factors influencing practice. RESULTS There were 178 responses to the survey (response rate 11.3%). The most frequently reported EOL practices were environmental modification (M=4.4/5, SD=0.4) and information sharing practices (M=4.4/5, SD=0.4). Emotional support practices were the least frequently reported practices by emergency care nurses (M=3.6/5, SD=0.9). Participants reported a lack of resources (M=2.4/5, SD=0.8) and opportunities to gain end-of-life care knowledge (M=2.9/5, SD=0.9). However, a generally positive attitude towards EOL care was indicated as participants reported strong agreement to palliative values (M=4.6/5, SD=0.4). CONCLUSIONS Results of this study suggest that most frequently reported EOL care practices of emergency care nurses require the least emotional engagement. The findings can inform areas of knowledge development and resources for emergency care nurses.
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Affiliation(s)
- Jose Aquino
- School of Nursing & Midwifery, Gold Coast Campus, Griffith University, Gold Coast, Qld Australia.
| | - Julia Crilly
- School of Nursing & Midwifery, Gold Coast Campus, Griffith University, Gold Coast, Qld Australia; Patient Centred Health Services, Menzies Health Institute Queensland, Griffith University, Gold Coast, Qld, Australia; Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Qld, Australia
| | - Kristen Ranse
- School of Nursing & Midwifery, Gold Coast Campus, Griffith University, Gold Coast, Qld Australia; Patient Centred Health Services, Menzies Health Institute Queensland, Griffith University, Gold Coast, Qld, Australia
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14
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Loffredo AJ, Chan GK, Wang DH, Goett R, Isaacs ED, Pearl R, Rosenberg M, Aberger K, Lamba S. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med 2021; 78:658-669. [PMID: 34353647 DOI: 10.1016/j.annemergmed.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.
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Affiliation(s)
- Anthony J Loffredo
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA
| | - David H Wang
- Division of Palliative Medicine, Scripps Health, San Diego, CA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Eric D Isaacs
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Rachel Pearl
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Rosenberg
- Department of Emergency Medicine, St Joseph's Health, Paterson and Wayne, NJ
| | - Kate Aberger
- Division of Palliative Medicine and Geriatrics, St Joseph's Health, Paterson, NJ; Department of Emergency Medicine, Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
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15
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Wright R, Lowton K, Hansen BR, Grocott P. Older adult and family caregiver preferences for emergency department based-palliative care: An experience-based co-design study. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2020.100016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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Gaucher N, Humbert N, Gauvin F. What Do We Know About Pediatric Palliative Care Patients Consulting to the Pediatric Emergency Department? Pediatr Emerg Care 2021; 37:e396-e400. [PMID: 30256320 DOI: 10.1097/pec.0000000000001620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to describe the characteristics of pediatric palliative care (PPC) patients presenting to a pediatric emergency department (ED) and these patients' ED visits. METHODS This retrospective chart review was conducted from April 1, 2007, to March 31, 2012, in a tertiary care pediatric university-affiliated hospital. Eligible patients had initial PPC consultations during the study period; all ED visits by these patients were included. Data were drawn from the ED's electronic data system and patient's medical chart. RESULTS A total of 290 new patients were followed by the PPC team, and 94 (32.4%) consulted the ED. Pediatric palliative care patients who consulted the ED had a median age of 7 years and baseline diagnoses of cancer (39.4%) or encephalopathy (27.7%). No patients died in the ED, but 36 (38.3%) died in hospital after an ED visit and 18 (19.1%) within 72 hours of admission. Pediatric palliative care patients consulted 219 times, with a median number of visits per patient of 2 (range, 1-8). They presented acutely ill as per triage scales. Reasons for consultation included respiratory distress/dyspnea (30.6%), pain (12.8%), seizure (11.4%), and fever (9.1%). Patients were often admitted to wards (61.2%) and the pediatric intensive care unit (7.3%). Two thirds (65.7%) of patients had signed an advanced care directive at the time of their visit. Discussions about goals of care occurred in 37.4% of visits. CONCLUSIONS Pediatric palliative care patients present to the ED acutely ill, often at their end of life, and goals of care are not always discussed. This is a first step toward understanding how to improve PPC patients' ED care.
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Affiliation(s)
| | - Nago Humbert
- Pediatric Palliative Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - France Gauvin
- Pediatric Palliative Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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17
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Wang RF, Lai CC, Fu PY, Huang YC, Huang SJ, Chu D, Lin SP, Chaou CH, Hsu CY, Chen HH. A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department. Palliat Med 2021; 35:408-416. [PMID: 33198575 DOI: 10.1177/0269216320972041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM We developed a screening model for predicting 1-year mortality. DESIGN A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.
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Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taipei
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
| | - Ping-Yeh Fu
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | | | | | - Dachen Chu
- Superintendent, Taipei City Hospital
- National Yang-Ming University, Taipei
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan City
| | - Chen-Yang Hsu
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
- Da-Chung Hospital, Miaoli
| | - Hsiu-Hsi Chen
- Division Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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Sadler K, Abudari G, Aljawi D, Snelling D. Deaths in the Emergency Department: An Assessment of Patient's End-of-Life Trajectory and Quality of Care. Indian J Palliat Care 2020; 26:352-357. [PMID: 33311879 PMCID: PMC7725167 DOI: 10.4103/ijpc.ijpc_206_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background: A considerable proportion of deaths occur in the emergency department (ED), and yet a palliative care approach is not well integrated. End-of-life patients often either receive invasive care, or their care is neglected due to being perceived as not being “acutely” ill. While a small proportion of these deaths are of an unpredictable nature, most have identifiable dying trajectories: (a) advanced cancer, (b) organ failure, (c) chronic frailty, and (d) sudden death. Aims: This study aims (1) to determine the incidence, nature and illness trajectory of deaths in the ED; (2) to examine to which extent end of life discussions took place; (3) to analyze the aggressiveness of the care; and (4) to determine if palliative care services were being consulted. Methods: This retrospective study was conducted in a large tertiary hospital and cancer center in Saudi Arabia over a 1 year period. Data collection included demographics, clinical presentation, end-of-life care, and palliative care involvement. Results: Our study included 103 patients. Cancer was the main diagnosis (45.7%). Deaths were related to advanced cancer (45.6%), followed by organ failure (29.1%), sudden death (13.6%), and chronic frailty (11.7%,). 35.9% had a documented Do-Not-Attempt-Resuscitation (DNAR) status prior to admission. 51.5% received aggressive treatments. Palliative care was consulted for 19.4% of patients, among which 50% of referrals occurred 1 day prior to death. Conclusions: End-of-life care discussions tend to occur late in the disease trajectory; a number of patients are subjected to aggressive treatments, and palliative care services remain underutilized. An early, integrated and collaborative approach is warranted to address the challenges of end of life care.
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Affiliation(s)
- Kim Sadler
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gassan Abudari
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Deena Aljawi
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - David Snelling
- Adult Emergency Department, Penn State Health Milton S Hershey Medical Center, Pennsylvania, USA
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19
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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Ann Emerg Med 2020; 76:751-756. [PMID: 32747084 DOI: 10.1016/j.annemergmed.2020.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 11/21/2022]
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20
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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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21
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Hasson F, Nicholson E, Muldrew D, Bamidele O, Payne S, McIlfatrick S. International palliative care research priorities: A systematic review. BMC Palliat Care 2020; 19:16. [PMID: 32013949 PMCID: PMC6998205 DOI: 10.1186/s12904-020-0520-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework. METHODS A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis. RESULTS The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas. CONCLUSIONS Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.
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Affiliation(s)
- Felicity Hasson
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland.
| | - Emma Nicholson
- UCD School of Nursing, Midwifery and Health Systems, UCD College of Health and Agricultural Sciences, University College Dublin, Belfield, Dublin 4, Ireland
| | - Deborah Muldrew
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland
| | - Olufikayo Bamidele
- Academcy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RZ, England
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, LA14YX, Lancaster, UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road, Newtownabbey, BT37 0QB, Northern Ireland
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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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Chen CH, Cheng YH, Chen FJ, Huang EY, Liu PM, Kung CT, Su CH, Chen SH, Chien PC, Hsieh CH. Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study). Risk Manag Healthc Policy 2019; 12:307-315. [PMID: 31849547 PMCID: PMC6911809 DOI: 10.2147/rmhp.s232983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms. Methods Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form. Results The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent. Conclusion This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.
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Affiliation(s)
- Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung 802, Taiwan
| | - Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, 736, Taiwan
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, Kaohsiung 824, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Po-Ming Liu
- Department of Emergency Medicine, Kaohsiung 802, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chao-Hui Su
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Shu-Hwa Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,School of Nursing, Fooyin University, Kaohsiung 831, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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Giles TM, Hammad K, Breaden K, Drummond C, Bradley SL, Gerace A, Muir-Cochrane E. Nurses' perceptions and experiences of caring for patients who die in the emergency department setting. Int Emerg Nurs 2019; 47:100789. [PMID: 31495727 DOI: 10.1016/j.ienj.2019.100789] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/16/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected. AIM This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED. METHODS Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically. RESULTS 211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected. CONCLUSIONS ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.
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Affiliation(s)
- Tracey M Giles
- College of Nursing and Midwifery, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Karen Hammad
- College of Nursing and Midwifery, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Katrina Breaden
- College of Nursing and Midwifery, Flinders University, Bedford Park, Adelaide, South Australia, Australia.
| | - Christine Drummond
- Central Adelaide Palliative Services, Woodville, Adelaide, South Australia, Australia
| | - Sandra L Bradley
- College of Nursing and Midwifery, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Adam Gerace
- CQ University, Wayville, Adelaide, South Australia, Australia
| | - Eimear Muir-Cochrane
- College of Nursing and Midwifery, Flinders University, Bedford Park, Adelaide, South Australia, Australia
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Tiernan E, Ryan J, Casey M, Hale A, O’Reilly V, Devenish M, Whyte B, Hollingsworth S, Price O, Callanan I, Walsh D, Normand C, May P. A quasi-experimental evaluation of an intervention to increase palliative medicine referral in the emergency department. J Health Serv Res Policy 2019; 24:155-163. [DOI: 10.1177/1355819619839087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To evaluate a new intervention intended to increase referral rates from the emergency department (ED) to the palliative medicine service (PMS) in acute hospitals. Methods We conducted a quasi-experimental evaluation in an urban teaching hospital in Dublin, Ireland. Data were collected over two eight-week periods in November/December 2013 and May/June 2015, with the PALliative Medicine in the Emergency Department (PAL.M.ED.™) intervention implemented in the intervening period. All adults who were admitted to the hospital via the ED during the two time periods and who received a palliative care consultation during their hospital stay were included in the study. Our primary analysis evaluated the impact of PAL.M.ED.™ on PMS referral in the ED. Our secondary analysis evaluated the impact of PMS referral in the ED on length of stay (LOS) and utilization, compared to PMS referral later in the admission. We controlled for observed confounding between groups using propensity scores. Results PAL.M.ED.™ was associated with an increase in PMS referral in the ED ( p < 0.005; odds ratio: 10.5 (95%CI: 3.8 to 28.7)). PMS referral in the ED was associated with shorter hospital LOS ( p < 0.005; −10.9 days (95%CI: −17.7 to −4.1)). Conclusions Low PMS referral rates in the ED, and the poor outcomes for patients and hospitals that arise from admissions of those with serious illness, may be mitigated by a proactive intervention to identify appropriate patients at admission.
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Affiliation(s)
- Eoin Tiernan
- Consultant in Palliative Medicine, Department of Palliative Medicine, St. Vincent’s University Hospital, Ireland
| | - John Ryan
- Consultant in Emergency Medicine, St. Vincent’s University Hospital, Ireland
| | - Mary Casey
- Research Assistant, SHO in Palliative Medicine, St. Vincent’s University Hospital, Ireland
| | - Aine Hale
- Registrar in Palliative Medicine, St. Vincent’s University Hospital, Ireland
| | - Valerie O’Reilly
- Locum Consultant in Palliative Medicine, Milford Hospice, Ireland
| | - Millie Devenish
- Clinical Nurse Specialist in Palliative Care, St. Vincent’s University Hospital, Ireland
| | - Barbara Whyte
- Clinical Nurse Specialist in Palliative Care, St. Vincent’s University Hospital, Ireland
| | - Siobhan Hollingsworth
- Clinical Nurse Specialist in Palliative Care, St. Vincent’s University Hospital, Ireland
| | - Olga Price
- Clinical Nurse Specialist in Palliative Care, St. Vincent’s University Hospital, Ireland
| | - Ian Callanan
- Clinical Audit Coordinator, St. Vincent’s Healthcare Group, Ireland
| | - Declan Walsh
- Chair, Department of Supportive Oncology, Levine Cancer Institute, Carolinas HealthCare System
- Professor of Medicine, Carolinas HealthCare System, Director, Center for Supportive Care and Survivorship, USA
| | - Charles Normand
- Edward Kennedy Professor of Health Policy & Management, Centre for Health Policy & Management, Trinity College Dublin, Ireland
- Professor in Health Economics, Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, UK
| | - Peter May
- Research Assistant Professor, Centre for Health Policy and Management, Trinity College Dublin, Ireland
- Visiting Research Fellow, The Irish Longitudinal study on Ageing, Trinity College Dublin, Ireland
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Palliative and end-of-life care education in Canadian emergency medicine residency programs: A national cross-sectional survey. CAN J EMERG MED 2019; 21:219-225. [DOI: 10.1017/cem.2018.470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjectivesEmergency physicians play an important role in providing care at the end-of-life as well as identifying patients who may benefit from a palliative approach. Several studies have shown that emergency medicine (EM) residents desire further training in palliative care. We performed a national cross-sectional survey of EM program directors. Our primary objective was to describe the number of Canadian postgraduate EM training programs with palliative and end-of-life care curricula.MethodsA 15-question survey in English and French was sent by email to all program directors of both the Canadian College of Family Physicians emergency medicine (CCFP(EM)) and the Royal College of Physicians and Surgeons of Canada emergency medicine (RCPSC-EM) postgraduate training programs countrywide using FluidSurveys™ with a modified Dillman approach.ResultsWe received a total of 26 responses from the 36 (response rate = 72.2%) EM postgraduate programs in Canada. Ten out of 26 (38.5%) programs had a structured educational program pertaining to palliative and end-of-life care. Lectures or seminars were the exclusive choice to teach content. Clinical palliative medicine rotations were mandatory in one out of 26 (3.8%) programs. The top two barriers to implementation of palliative and end-of-life care curricula were lack of time (84.6%) and curriculum development concerns (80.8%).ConclusionsPalliative and end-of-life care training within EM has been identified as an area of need. This cross-sectional survey demonstrates that a minority of Canadian EM programs have palliative and end-of-life care curricula. It will be important for all EM training programs, RCPSC-EM and CCFP(EM), in Canada, to develop an agreed upon set of competencies and to structure their curricula around them.
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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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Booth A, Maddison J, Wright K, Fraser L, Beresford B. Research prioritisation exercises related to the care of children and young people with life-limiting conditions, their parents and all those who care for them: A systematic scoping review. Palliat Med 2018; 32:1552-1566. [PMID: 30404588 PMCID: PMC6238162 DOI: 10.1177/0269216318800172] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In planning high-quality research in any aspect of care for children and young people with life-limiting conditions, it is important to prioritise resources in the most appropriate areas. AIM To map research priorities identified from existing research prioritisation exercises relevant to infants, children and young people with life-limiting conditions, in order to inform future research. DESIGN We undertook a systematic scoping review to identify existing research prioritisation exercises; the protocol is publicly available on the project website. DATA SOURCES The bibliographic databases ASSIA, CINAHL, MEDLINE/MEDLINE In Process and Embase were searched from 2000. Relevant reference lists and websites were hand searched. Included were any consultations aimed at identifying research for the benefit of neonates, infants, children and/or young people (birth to age 25 years) with life-limiting, life-threatening or life-shortening conditions; their family, parents, carers; and/or the professional staff caring for them. RESULTS A total of 24 research prioritisation exercises met the inclusion criteria, from which 279 research questions or priority areas for health research were identified. The priorities were iteratively mapped onto an evolving framework, informed by World Health Organization classifications. This resulted in identification of 16 topic areas, 55 sub-topics and 12 sub-sub-topics. CONCLUSION There are numerous similar and overlapping research prioritisation exercises related to children and young people with life-limiting conditions. By mapping existing research priorities in the context in which they were set, we highlight areas to focus research efforts on. Further priority setting is not required at this time unless devoted to ascertaining families' perspectives.
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Affiliation(s)
- Alison Booth
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
| | - Jane Maddison
- Social Policy Research Unit, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
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McCallum KJ, Jackson D, Walthall H, Aveyard H. Exploring the quality of the dying and death experience in the Emergency Department: An integrative literature review. Int J Nurs Stud 2018; 85:106-117. [DOI: 10.1016/j.ijnurstu.2018.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 10/16/2022]
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Bush RA, Pérez A, Baum T, Etland C, Connelly CD. A systematic review of the use of the electronic health record for patient identification, communication, and clinical support in palliative care. JAMIA Open 2018; 1:294-303. [PMID: 30842998 PMCID: PMC6398614 DOI: 10.1093/jamiaopen/ooy028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives Globally, healthcare systems are using the electronic health record (EHR) and elements of clinical decision support (CDS) to facilitate palliative care (PC). Examination of published results is needed to determine if the EHR is successfully supporting the multidisciplinary nature and complexity of PC by identifying applications, methodology, outcomes, and barriers of active incorporation of the EHR in PC clinical workflow. Methods A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The data sources PubMed, CINAL, EBSCOhost, and Academic Search Premier were used to identify literature published 1999–2017 of human subject peer-reviewed articles in English containing original research about the EHR and PC. Results The search returned 433 articles, 30 of which met inclusion criteria. Most studies were feasibility studies or retrospective cohort analyses; one study incorporated prospective longitudinal mixed methods. Twenty-three of 30 (77%) were published after 2014. The review identified five major areas in which the EHR is used to support PC. Studies focused on CDS to: identify individuals who could benefit from PC; electronic advanced care planning (ACP) documentation; patient-reported outcome measures (PROMs) such as rapid, real-time pain feedback; to augment EHR PC data capture capabilities; and to enhance interdisciplinary communication and care. Discussion Beginning in 2015, there was a proliferation of articles about PC and EHRs, suggesting increasing incorporation of and research about the EHR with PC. This review indicates the EHR is underutilized for PC CDS, facilitating PROMs, and capturing ACPs.
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Affiliation(s)
- Ruth A Bush
- Beyster Institute of Nursing Research, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA
| | - Alexa Pérez
- Beyster Institute of Nursing Research, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA
| | - Tanja Baum
- Beyster Institute of Nursing Research, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA
| | - Caroline Etland
- Beyster Institute of Nursing Research, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA.,Education, Department of Research and Professional Practice, Sharp Chula Vista Medical Center, Sharp Healthcare System San Diego, San Diego, California, USA
| | - Cynthia D Connelly
- Beyster Institute of Nursing Research, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA
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Shoenberger J, Lamba S, Goett R, DeSandre P, Aberger K, Bigelow S, Brandtman T, Chan GK, Zalenski R, Wang D, Rosenberg M, Jubanyik K. Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework. AEM EDUCATION AND TRAINING 2018; 2:130-145. [PMID: 30051080 PMCID: PMC6001832 DOI: 10.1002/aet2.10088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM. METHODS The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine. RESULTS The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators. CONCLUSIONS Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.
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Affiliation(s)
- Jan Shoenberger
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCA
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Spiritual perspectives of emergency medicine doctors and nurses in caring for end-of-life patients: A mixed-method study. Int Emerg Nurs 2018; 37:13-22. [DOI: 10.1016/j.ienj.2017.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 11/20/2022]
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Díaz-Cortés MDM, Granero-Molina J, Hernández-Padilla JM, Pérez Rodríguez R, Correa Casado M, Fernández-Sola C. Promoting dignified end-of-life care in the emergency department: A qualitative study. Int Emerg Nurs 2018; 37:23-28. [DOI: 10.1016/j.ienj.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/11/2017] [Accepted: 05/28/2017] [Indexed: 10/19/2022]
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Sakashita A, Morita T, Kishino M, Aoyama M, Kizawa Y, Tsuneto S, Shima Y, Miyashita M. Which Research Questions Are Important for the Bereaved Families of Palliative Care Cancer Patients? A Nationwide Survey. J Pain Symptom Manage 2018; 55:379-386. [PMID: 28935131 DOI: 10.1016/j.jpainsymman.2017.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/08/2017] [Accepted: 09/10/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT Bereaved family members are present from diagnosis to the end of life and can look back and evaluate the experience; in addition, the family itself is also an important subject in the care of the patient. Therefore, although it is essential to determine the priority research issues from the viewpoint of the patients and health care workers, it is also crucial to know the important research themes from the viewpoint of the bereaved family members. OBJECTIVES The purpose of this study was to identify research priorities for palliative care in Japan, based on the viewpoint of bereaved family members. METHODS/DESIGN We conducted a cross-sectional, self-report questionnaire survey. Content analysis was performed on free-text answers for research priorities. This study was carried out as part of the third Japan HOspice and Palliative Care Evaluation (J-HOPE3) study. RESULTS We extracted 1658 codes from the transcripts and organized them into 120 subcategories on the basis of similarity. Subcategories were then organized into eight categories as follows: <improvement in the structure of palliative care services>; <pain relief>; <communication>; <symptom management, other than pain>; <better care and assistance methods>; <publicizing and raising awareness of palliative care>; <cancer medical services>; and <knowledge, skill, and attitude of medical staff>. CONCLUSION The findings of this study can be used as a research agenda for palliative care, which should take first priority in the future, and could be carried out using limited resources.
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Affiliation(s)
- Akihiro Sakashita
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Megumi Kishino
- Division of Nursing, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Maho Aoyama
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- Tsukuba Medical Center Foundation, Home Care Service, Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Cotogni P, De Luca A, Saini A, Brazzi L. Unplanned hospital admissions of palliative care patients: a great challenge for internal and emergency medicine physicians. Intern Emerg Med 2017; 12:569-571. [PMID: 28477288 DOI: 10.1007/s11739-017-1671-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/25/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, C.so Bramante 88/90, 10126, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
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Lederman Z, Baird G, Dong C, Leong BSH, Pal RY. Attitudes of Singapore Emergency Department staff towards family presence during cardiopulmonary resuscitation. ACTA ACUST UNITED AC 2017. [DOI: 10.1177/1477750917706175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zohar Lederman
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Geraldine Baird
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | - Chaoyan Dong
- Sneaking Health, SingHealth, Singapore, Singapore
| | - Benjamin SH Leong
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | - Rakhee Y Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
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Weng TC, Yang YC, Chen PJ, Kuo WF, Wang WL, Ke YT, Hsu CC, Lin KC, Huang CC, Lin HJ. Implementing a novel model for hospice and palliative care in the emergency department: An experience from a tertiary medical center in Taiwan. Medicine (Baltimore) 2017; 96:e6943. [PMID: 28489813 PMCID: PMC5428648 DOI: 10.1097/md.0000000000006943] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.
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Affiliation(s)
| | | | - Ping-Jen Chen
- Palliative Care Center, Chi-Mei Medical Center
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Department of Geriatrics and Gerontology, Chi-Mei Medical Center, Tainan
| | | | | | - Ya-Ting Ke
- Department of Nursing
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Graduate Institute of Nursing, Kaohsiung Medical University, Kaohsiung
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology
| | - Kao-Chang Lin
- Holistic Care Unit, Department of Internal Medicine
- Department of Biotechnology, Southern Taiwan University of Science and Technology
| | - Chien-Cheng Huang
- Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology
- Department of Geriatrics and Gerontology, Chi-Mei Medical Center, Tainan
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University
- Department of Occupational Medicine, Chi-Mei Medical Center, Tainan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology
- Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
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Haydar SA, Almeder L, Michalakes L, Han PKJ, Strout TD. Using the Surprise Question To Identify Those with Unmet Palliative Care Needs in Emergency and Inpatient Settings: What Do Clinicians Think? J Palliat Med 2017; 20:729-735. [PMID: 28437203 DOI: 10.1089/jpm.2016.0403] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The surprise question (SQ), "Would you be surprised if this patient died within the next year?" is effective in identifying end-stage renal disease and cancer patients at high risk of death and therefore potentially unmet palliative care needs. Following implementation of the SQ in our acute care setting, we sought to explore hospital-based providers' perceptions of the tool. OBJECTIVES To evaluate (1) providers' perceptions regarding the feasibility of SQ use in emergency and inpatient settings, (2) clinician perceptions regarding the utility of the SQ, and (3) barriers to SQ use. DESIGN A cross-sectional survey of medical providers following addition of the SQ to the electronic record for all patients admitted to a tertiary care hospital. RESULTS A total of 111/203 (55%) providers participated: 48/57 (84%) emergency physicians (EPs) and 63/146 (43%) inpatient providers (IPs). Most reported no difficulty using the SQ. Modest numbers in both groups reported that the SQ influenced care delivery (EPs 37%, IPs 42%) as well as goals of care (EPs 45%, IPs 52%). At least some advance care planning discussions were prompted by the SQ (EPs 45%, IPs 58%). Team discussions were influenced by SQ use for more than half of each group. Most respondents (55%) expressed some concern that their SQ responses could be inaccurate. CONCLUSIONS In this setting, clinicians indicated that use of the SQ is feasible, acceptable, and useful in facilitating advance care planning discussions among teams, patients, and families. Many reported that SQ use influenced goals of care, but concern regarding accuracy was a barrier. Additional research examining SQ accuracy and predictive ability is warranted.
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Affiliation(s)
- Samir A Haydar
- 1 Department of Emergency Medicine, Maine Medical Center, Tufts University School of Medicine , Portland, Maine
| | - Lisa Almeder
- 2 Maine Medical Partners Hospital Medicine , Maine Medical Partners Internal Medicine, Portland, Maine
| | - Lauren Michalakes
- 3 Hospice and Palliative Care, Pen Bay Medical Center , Rockport, Maine
| | - Paul K J Han
- 4 Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute , Portland, Maine
| | - Tania D Strout
- 1 Department of Emergency Medicine, Maine Medical Center, Tufts University School of Medicine , Portland, Maine
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Green E, Gott M. Palliative care in the emergency department: avoidable or appropriate? Br J Hosp Med (Lond) 2016; 77:674-675. [DOI: 10.12968/hmed.2016.77.12.674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Emilie Green
- Academic Clinical Fellow in General Practice, Royal Free London NHS Foundation Trust, London NW3 2QG
| | - Merryn Gott
- Professor of Health Sciences and Director of Research, School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
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George NR, Kryworuchko J, Hunold KM, Ouchi K, Berman A, Wright R, Grudzen CR, Kovalerchik O, LeFebvre EM, Lindor RA, Quest TE, Schmidt TA, Sussman T, Vandenbroucke A, Volandes AE, Platts-Mills TF. Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda. Acad Emerg Med 2016; 23:1394-1402. [PMID: 27611892 DOI: 10.1111/acem.13083] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.
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Affiliation(s)
- Naomi R. George
- Department of Emergency Medicine; Brown University; Providence RI
| | | | | | - Kei Ouchi
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA
| | - Amy Berman
- Hartford Program Officer/Patient Representative; New York NY
| | - Rebecca Wright
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | - Corita R. Grudzen
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | | | - Eric M. LeFebvre
- Department of Emergency Medicine, Geriatric Fellow; University of North Carolina-Chapel Hill; Chapel Hill NC
| | | | - Tammie E. Quest
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Terri A. Schmidt
- Departments of Emergency Medicine and Hematology/Oncology; Oregon Health and Science University; Portland OR
| | - Tamara Sussman
- School of Social Work; McGill University; Montreal Quebec Canada
| | | | | | - Timothy F. Platts-Mills
- Department of Emergency Medicine and Department of Anesthesiology; University of North Carolina-Chapel Hill; Chapel Hill NC
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Lamba S, DeSandre PL, Quest TE. Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine. J Emerg Med 2016; 51:658-667. [PMID: 27613448 DOI: 10.1016/j.jemermed.2016.06.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/28/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. DISCUSSION We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. CONCLUSION The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Paul L DeSandre
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia
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Revels A, Sabo B, Snelgrove-Clarke E, Price S, Field S, Helwig M. Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol. ACTA ACUST UNITED AC 2016; 14:75-86. [PMID: 27532465 DOI: 10.11124/jbisrir-2016-002647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTIONS/OBJECTIVES The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?
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Affiliation(s)
- Amanda Revels
- 1School of Nursing, Dalhousie University 2Faculty of Medicine, Dalhousie University 3Department of Pediatrics, IWK Health Centre 4Department of Emergency Medicine, Capital District Health Authority 5WK Kellogg Health Sciences Library, Dalhousie University 6Department of Obstetrics & Gynecology, IWK Health Centre, Halifax, Nova Scotia, Canada
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Bowman J, George N, Barrett N, Anderson K, Dove-Maguire K, Baird J. Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers. Acad Emerg Med 2016; 23:694-702. [PMID: 26990541 DOI: 10.1111/acem.12963] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/03/2016] [Accepted: 03/05/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Palliative Care and Rapid Emergency Screening (P-CaRES) Project is an initiative intended to improve access to palliative care (PC) among emergency department (ED) patients with life-limiting illness by facilitating early referral for inpatient PC consultations. In the previous two phases of this project, we derived and validated a novel PC screening tool. This paper reports on the third and final preimplementation phase. OBJECTIVES Examine the acceptability of the P-CaRES tool among PC and ED providers as well as test its reliability on case vignettes. Compare variations in reliability and acceptability of the tool based on ED providers' roles (attendings, residents, and nurses) and lengths of experience. METHODS A two-part electronic survey was distributed to ED providers at multiple sites across the United States. We tested the reliability of the tool in the first part of the survey, through a series of case vignettes. A criterion standard of correct responses was first defined by consensus input from expert PC physicians' interpretations of the vignettes. The experts' input was validated using the Gwet's AC1 coefficient for inter-rater reliability. ED providers were then presented with the case vignettes and asked to use the P-CaRES tool to correctly identify which patients had unmet PC needs. ED provider responses were compared both against the criterion standard and against different subsets of respondents (divided both by role and by level of experience). The second part of the survey assessed acceptability of the P-CaRES tool among ED providers using responses to questions from a modified Ottawa Acceptability of Decision Rules Instrument, based on a 1-5 Likert rating scale. Descriptive statistics were used to report all outcomes. RESULTS In total, 213 ED providers employed in three different regions across the country responded to the survey (39.4%) and 185 (86.9%) of those completed it. The majority of providers felt that the tool would be useful in their practice (80.5%), agreed that the tool was clear and unambiguous (87.1%), thought that use of the tool would likely benefit patients (87.5%), and thought that it would result in improved use of resources to help severely ill patients (83.6%). Over three-quarters of ED providers (78.5%) also self-reported that they refer patients with unmet PC needs less than 10% of the time, and only 10.8% of respondents believed that they are already utilizing an effective strategy to screen or refer patients to PC. Applying our P-CaRES tool to case vignettes, ED providers generated PC referrals in concordance with PC experts over 88.7% of the time (95% confidence interval = 86.4% to 90.6%), with an overall sensitivity of more than 90%. These results varied minimally regardless of the respondent's role in the ED or their level of experience. CONCLUSION Screening by emergency medicine providers for unmet PC needs using a brief, novel, content-validated screening tool is acceptable and is also reliable when applied to case vignettes-regardless of provider role or experience. Clinical trial and further study are warranted and are currently under way.
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Affiliation(s)
- Jason Bowman
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Naomi George
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | | | | | - Kalie Dove-Maguire
- Department of Emergency Medicine; University of California at San Francisco; San Francisco CA
| | - Janette Baird
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
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Miranda B, Vidal SA, Mello MJGD, Lima JTDO, Rêgo JC, Pantaleão MC, Leão VGC, Gusmão Filho FARD, Costa Júnior JID. Cancer patients, emergencies service and provision of palliative care. Rev Assoc Med Bras (1992) 2016; 62:207-11. [DOI: 10.1590/1806-9282.62.03.207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 05/04/2015] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Objective: To describe the clinical and sociodemographic profile of cancer patients admitted to the Emergency Center for High Complexity Oncologic Assistance, observing the coverage of palliative and home care. Method: Cross sectional study including adult cancer patients admitted to the emergency service (September-December/2011) with a minimum length of hospital stay of two hours. Student’s t-test and Pearson chi-square test were used to compare the means. Results: 191 patients were enrolled, 47.6% elderly, 64.4% women, 75.4% from the city of Recife and greater area. The symptom prevalent at admission was pain (46.6%). 4.2% of patients were linked to palliative care and 2.1% to home care. The most prevalent cancers: cervix (18.3%), breast (13.6%) and prostate (10.5%); 70.7% were in advanced stages (IV, 47.1%); 39.4% without any cancer therapy. Conclusion: Patients sought the emergency service on account of pain, probably due to the incipient coverage of palliative and home care. These actions should be included to oncologic therapy as soon as possible to minimize the suffering of the patient/family and integrate the skills of oncologists and emergency professionals.
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Affiliation(s)
- Bruno Miranda
- Instituto de Medicina Integral Prof. Fernando Figueira, Brazil
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Kraus CK, Greenberg MR, Ray DE, Dy SM. Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors. J Pain Symptom Manage 2016; 51:898-906. [PMID: 26988848 DOI: 10.1016/j.jpainsymman.2015.12.334] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority. OBJECTIVES To assess PC competency education in EM residency programs. METHODS This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training. RESULTS Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues. CONCLUSION There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.
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Affiliation(s)
- Chadd K Kraus
- Department of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
| | - Marna R Greenberg
- Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Daniel E Ray
- Section of Palliative Medicine and Hospice, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sydney Morss Dy
- Duffey Pain/Palliative Care Program, Johns Hopkins Kimmel Cancer Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Tse JWK, Hung MSY, Pang SMC. Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study. J Emerg Nurs 2016; 42:224-32. [PMID: 27033338 DOI: 10.1016/j.jen.2015.10.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/11/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Provision of end-of-life (EOL) care in the emergency department has improved globally in recent years and has a different scope of interventions than traditional emergency medicine. In 2010, a regional hospital established the first ED EOL service in Hong Kong. METHODS The aim of this study was to understand emergency nurses' perceptions regarding the provision of EOL care in the emergency department. A qualitative approach was used with purposive sampling of 16 nurses who had experience in providing EOL care. Semi-structured, face-to-face interviews were conducted from May to October, 2014. All the interviews were transcribed verbatim for content analysis. RESULTS Four themes were identified: (1) doing good for the dying patients, (2) facilitating family engagement and involvement, (3) enhancing personal growth and professionalism, and (4) expressing ambiguity toward resource deployment. DISCUSSION Provision of EOL care in the emergency department can enhance patients' last moment of life, facilitate the grief and bereavement process of families, and enhance the professional development of staff in emergency department. It is substantiated that EOL service in the emergency department enriches EOL care in the health care system. Findings from this study integrated the perspectives on ED EOL services from emergency nurses. The integration of EOL service in other emergency departments locally and worldwide is encouraged.
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Affiliation(s)
| | - Maria Shuk Yu Hung
- Hong Kong Special Administrative Region of the People's Republic of China
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George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. J Pain Symptom Manage 2016; 51:108-19.e2. [PMID: 26335763 DOI: 10.1016/j.jpainsymman.2015.07.017] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 07/02/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects. OBJECTIVES To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED. METHODS Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. RESULTS Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral. CONCLUSION We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.
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Affiliation(s)
- Naomi George
- Brown University Alpert Medical School, Providence, Rhode Island, USA.
| | | | | | - Carolyn Song
- Mount Sinai School of Medicine, New York, New York, USA
| | | | - Corita Grudzen
- New York University Langone Medical Center, New York, New York, USA
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Revels A, Goldberg L, Watson J. Caring Science: A Theoretical Framework for Palliative Care in the Emergency Department. ACTA ACUST UNITED AC 2016. [DOI: 10.20467/1091-5710-20.4.206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Fassier T, Valour E, Colin C, Danet F. Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study. Ann Emerg Med 2015; 68:28-39.e3. [PMID: 26619758 DOI: 10.1016/j.annemergmed.2015.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/19/2015] [Accepted: 09/29/2015] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface. METHODS This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France). RESULTS Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care. CONCLUSION These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.
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Affiliation(s)
- Thomas Fassier
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France.
| | - Elizabeth Valour
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France
| | - Cyrille Colin
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France; Medical Information, Evaluation and Research Unit, Hospices Civils de Lyon, Lyon, France
| | - François Danet
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France
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