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

Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission

BACKGROUND

Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population.

METHODS

We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis.

RESULTS

Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile.

CONCLUSIONS

Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.

TEMPORARY REMOVAL: Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

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Missed Opportunity to Diagnose Palliative Care Need Among Older Emergency Department Patients in a Middle-Income Country: A Retrospective Study

Purpose

This study aimed to determine the percentage of missed opportunities (MOs) to identify and treat older adults presenting with palliative care (PC) needs at one emergency department (ED). The secondary objective was to determine the rate of treatment interventions regardless of whether the patients received a PC plan as well as the direct cost of treatment.

Patients and Methods

In this retrospective study, PC need was determined using broad and narrow criteria. The subjects comprised patients aged 65 or older who had out-of-hospital cardiac arrest and/or died in the ED (Group 1) or within 72 hours after ED disposition (Group 2) over a 3-year period (2016-2018). Overall, 17,414 older adults visited the ED, 60 died in the ED, and 400 died within 72 hours after ED disposition and admitted to in-hospital ward. In total, 200 patients were randomly selected; of these, 15 were excluded.

Results

Of the remaining 185 patients enrolled, 161/185 (87%) met the PC criteria and 60/161 (37.3%) were missed opportunities for PC planning. Group 1, had thirty patients, and 8 of those 30 (27%) were missed opportunities for PC planning. Group 2, 131/161 (81.4%), died within 72 hours, and there were 52 missed opportunities (39.7%) of ED PC planning. By comorbidity (Group 2), providers considered PC planning most often for cancer patients (PC: 41.8%; missed opportunities: 15.4%; p = 0.001) and there were more missed opportunities for PC planning among those with ischemic heart disease (PC: 19.0%; missed opportunities: 36.5%; p = 0.025).

Conclusion

Of the older adults who visited the ED, 87% merited palliative care; further, 37% of opportunities for PC planning were missed. Providers considered PC planning most often for cancer patients. Recognizing PC needs and initiating care in the ED can improve end-of-life quality for dying patients.

Perspectives of emergency department physicians and nurses on reasons for preventable emergency department visits by patients with cancer

BACKGROUND

Patients with cancer frequently visit the emergency department (ED) for medical care, yet approximately half of ED visits for patients with cancer are thought to be preventable. Preventable ED visits are associated with increased healthcare costs and poor patient experiences and outcomes. The voices of ED providers who work with patients with cancer in their everyday practices have not been solicited as it pertains to preventable visits.

OBJECTIVES

The purpose of this study is to describe the perspectives of ED physicians and nurses on reasons for preventable ED visits by patients with cancer.

METHODS

A qualitative descriptive design guided the study. We conducted 23 semi-structured interviews with ED physicians and nurses to query them about their perspectives on the reasons for preventable ED visits by patients with cancer. Content analysis was conducted to list and describe the reasons they discussed.

RESULTS

Participants identified five "medical" and five "non-medical" causes of preventable ED visits. Medical reasons included uncontrolled cancer pain, gastrointestinal symptoms, anemia, fever, and on-going undiagnosed signs and symptoms. Non-medical reasons include patient hesitancy to contact primary care providers, lack of availability or responsiveness of primary providers, lack of access, lack of care coordination, and fears about diagnosis and treatment.

CONCLUSION

The voices of ED providers should be included in discussions about the problem of preventable ED visits by patients with cancer. The reasons supplied by the participants suggest that solutions to the problem will need to occur at the patient, provider, system, and societal levels.

Healthcare professionals' perspectives of the management of people with palliative care needs in the emergency department of a UK hospital

BACKGROUND

The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,''REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients.

METHODS

This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis.

RESULTS

Over the four years (2013-2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7.

CONCLUSIONS

A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

IMPORTANCE

An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

OBJECTIVE

To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

RESULTS

Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

CONCLUSIONS AND RELEVANCE

In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID

Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

BACKGROUND

Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes.

METHODS

A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer-reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis.

RESULTS

Twenty-three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end-of-life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED-PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC.

CONCLUSIONS

PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED.

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

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

Mapping the future for research in emergency medicine palliative care: A research roadmap

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.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand

Background

The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality.

Methods

A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included.

Results

A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was ‘cannot control symptoms’ (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality.

Conclusion

The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01009-z.

Main reasons and predictive factors of cancer-related emergency department visits in a Hungarian tertiary care center

BACKGROUND

Identifying the reasons for the Emergency Department (ED) visit of patients with cancer would be essential for possibly decreasing the burden of ED use. The aim of our study was to analyze the distribution of the demographic and clinical parameters of patients with cancer based on the reasons for the ED visits and to identify possible predictive factors for their visits.

METHODS

This retrospective study, carried out at a large, public tertiary hospital in Hungary, involved all patients 18 years or over, who had received a cancer diagnosis latest within five years of their visit to the ED in 2018. Demographic and clinical characteristics were collected partly via automated data collection and partly through the manual chart review by a team of experts, including six emergency physicians and an oncologist. Five main reasons for the ED visit were hypothesized, pilot-tested, then identified, including those with cancer-related ED visits (whose visit was unambiguously related to their cancer illness) and those with non-cancer-related ED visits (whose visit to the ED was in no way associated with their cancer illness.) A descriptive approach was used for data analysis and binary logistic regression was used to determine predictive factors for patients with cancer visiting the ED.

RESULTS

23.2% of the altogether 2383 ED visits were directly cancer-related, and these patients had a significantly worse overall survival than patients with non-cancer related ED visits. Age 65 or below (Odds Ratio: 1.51), presence of two more comorbidities (OR: 7.14), dyspnea as chief complaint (OR: 1.52), respiratory cancer (OR: 3.37), any prior chemotherapy (OR: 1.8), any prior immune/biological treatment (OR: 2.21), any prior Best Supportive Care/palliative care (OR: 19.06), or any prior hospice care (OR: 9.43), and hospitalization (OR:2.88) were independent risk factors for the ED visit to be cancer-related.

CONCLUSIONS

Our study is the first to identify independent predictive factors of ED use by patients with cancer based on the chief cause of their visit in the Central and Eastern European region. These results may provide important information for the development of algorithms intended to identify the needs of care of patients with cancer at the ED.

Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea

Background

High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.

Methods

We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.

Results

Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).

Conclusions

Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00988-3.

Emergency department presentations in palliative care patients: a retrospective cohort study

OBJECTIVES

To map the patient journey for individuals known to palliative care presenting to the emergency department (ED).

METHODS

A linked dataset from the CUREd database and palliative care services in a region in the North of England was used. The study describes day and time of presentations, events occurring in the ED, mode of leaving the department and length of hospital admissions for presentations occurring within 90 days of a contact with palliative care. Findings were compared with the wider population in the CUREd database.

RESULTS

A significant proportion of individuals known to palliative care (29.4%) presented to the ED. Presentations typically occurred in working hours. Most presented by ambulance (84.4%) and were admitted to hospital (75.1%); these observations persisted across age groups. Most presentations involved investigations (88.5%) and/or treatment (84.1%).

CONCLUSIONS

Palliative patients exhibit significant use of the ED; some have the potential to benefit from attendances, but there is a minority for whom ED is unlikely to have improved their care. Advance care planning and communication between services are important for empowering those who stand to benefit from ED, while ensuring appropriate care is planned for those who prefer to avoid presenting.

Strategies for knowledge translation of a palliative approach outside specialized palliative care services: a scoping review

Objectives

Research suggests palliative care to be translated and integrated in non-specialized palliative care services throughout the palliative care continuum across populations and settings. A need has been identified to build on the existing research literature in order to design strong knowledge translation strategies that can be evaluated in future research. The aim was to map strategies for knowledge translation of a palliative approach to care into non-specialized palliative care services for adult patients. The objectives were to explore the primary research activities, the specific type of knowledge translation strategies used, the research designs and study settings for such evaluations along with the major results thereof, and to identify major research gaps in this area.

Methods

A scoping review was performed to map the volume and characteristics of research literature (project registered in PROSPERO #2018 CRD42018100663). The ten-year period 2010 to 2019 was searched in six major databases for original articles published in English in which the knowledge translation of a palliative approach for adult patients was evaluated in non-specialized palliative healthcare settings, and all type of empirical data-based research designs. We excluded non-English, non-empirical articles, non-evaluation of knowledge translations, specialized palliative care settings, and other types of publications (i.e. non-original articles).

Results

Most of the 183 included articles focused on patients with cancer who were dying in hospitals and in high income countries. Only 13 articles focused on early palliative care. A palette of different strategies was used to implement palliative care in non-specialist palliative settings; no strategy was identified as outstanding. The majority of the articles had unspecified essential components of the research designs.

Conclusion

Previous suggestions for utilization of implementation science for knowledge translation of a palliative approach to care into non-specialized palliative care services are confirmed, and established knowledge translation theories can strengthen the field. To advance this specific field of knowledge, meticulously detailed reporting of studies is required as related to research designs, clarifications of contextual influences and mechanisms at work. Specific systematic reviews and meta-syntheses in the field are merited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00929-0.

End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review

INTRODUCTION

End of life (EOL) care in the Emergency Department (ED) requires focused, person-centred care to meet the needs of this vulnerable cohort of patients.

METHODS

An integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted. Studies were included if they were primary research relating to patients in the ED at the EOL, and/or evaluated EOL care pathways in the ED. Databases OVID Emcare, OVID Medline, and Scopus were searched from 1966-September 2021; followed by screening and appraisal. Articles were compared and data grouped into categories.

RESULTS

Eleven research articles were included generating three categories for EOL care in ED. 1) tools/criteria to identify patients who may require EOL care in ED; 2) processes for providing EOL care, and 3) implementation methods/frameworks to support the uptake of EOL care processes.

CONCLUSION

There were some commonalities in the criteria used to identify patients who may be at their EOL and the interventions implemented thereafter. There was no standardised process for screening for or treating EOL care needs in the ED. Further research is required to determine the impact that EOL care pathways have on patient and health service outcomes to inform strategies for future policy development.

Emergency Department Utilisation by Palliative Patients in a Regional Australian Setting

BACKGROUND

Many palliative care patients attend emergency departments (EDs) in acute Hospital. However, very limited studies inform about their presentations and appropriateness.

OBJECTIVES

This study explored the reasons and appropriateness of palliative care presentations in a regional Australian ED setting.

METHODS

A retrospective, single-centre observational study was conducted in a regional Australian hospital. All patients between January and December 2018 known to palliative care services presented to ED were included. Appropriateness of presentations was determined based on urgency of tests and treatments received, and practicability of obtaining these in a different setting.

RESULTS

A total of 35 patients made 85 presentations to the ED in 2018. The most common individual presenting complaints were shortness of breath (18.9%) followed by pain (14.1%), fever (11.8%), fall (8.2%), reduced oral intake or dehydration (8.2%), and bleeding (8.2%). The patients were brought by an ambulance in 56.5% presentations, and 63.5% presentations were admitted. About 93% presentations were referred by community healthcare professionals or required urgent investigation or management.

CONCLUSIONS

This study found the majority of presentations were appropriate since their management could not be delivered at other primary care settings. This study adds value to the growing body of evidence and supports future multi-site longitudinal studies.

"Resuscitate and Push": End-of-Life Care Experiences of Healthcare Staff in the Emergency Department - A Hermeneutic Phenomenological Study

OBJECTIVE

Care in the emergency department focuses significantly on delivering lifesaving/ life-sustaining clinical actions, often with limited attention to health-related suffering even at the end-of-life. How healthcare staff experience and navigate through the end-of-life phase remains minimally explored. Thus, this study aimed to uncover the lived experiences of emergency department staff at the end-of-life.

METHODS

van Manen's hermeneutic phenomenological approach was used. Nineteen healthcare staff were purposively recruited and interviewed. Interviews were audio-taped, transcribed verbatim, and thematic categories formulated. The existential lifeworld themes (corporeality, relationality, spatiality, and temporality) were used as heuristic guides for reflecting and organizing the lived experiences of participants.

RESULTS

The overarching category, 'resuscitate and push', was captured as corporeality (resisting death and dying); relationality (connectedness to the body of the patient; and lacking support for family and self); spatiality (navigating through a liminal space and lack of privacy for patients); and temporality (having limited to no time for end-of-life care and grieving). The end-of-life space was unpleasant. Although participants experienced helplessness and feelings of failure, support systems to help them to navigate through these emotions were lacking. Grief was experienced covertly and concealed by the entry of a new patient.

CONCLUSION

End-of-life in the emergency department is poorly defined. In addition to shifting from the traditional emergency care model to support the streamlining of palliative care in the department, staff will require support with navigating through the liminal space, managing their grief, and developing a better working relationship with patients/ families.

Palliative care in the emergency department: A qualitative study exploring barriers, facilitators, desired clinician qualities, and future directions

OBJECTIVE

To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED-PC, and clinicians' perspectives on the future of ED-PC.

METHOD

This qualitative study using semi-structured interviews was conducted in June-August 2020. Interviews were analyzed via a two-phase Rapid Analysis. The study's primary outcomes (innovations in ED-PC during COVID) are published elsewhere. In this secondary analysis, we examine interviewee responses to broader questions about ED-PC currently and in the future.

RESULTS

PC providers perceived as successful in their work in the ED were described as autonomous, competent, flexible, fast, and fluent in ED language and culture. Barriers to ED-PC integration included the ED environment, lack of access to PC providers at all times, the ED perception of PC, and the lack of a supporting financial model. Facilitators to ED-PC integration included proactive identification of patients who would benefit from PC, ED-focused PC education and tools, PC presence in the ED, and data supporting ED-PC. Increased primary PC education for ED staff, increased automation, and innovative ED-PC models were seen as areas for future growth.

SIGNIFICANCE OF RESULTS

Our findings provide useful information for PC programs considering expanding their ED presence, particularly as this is the first study to our knowledge that examines traits of successful PC providers in the ED environment. Our findings also suggest that, despite growth in the arena of ED-PC, barriers and facilitators remain similar to those identified previously. Future research is needed to evaluate the impact that ED-PC initiatives may have on patient and system outcomes, to identify a financial model to maintain ED-PC integration, and to examine whether perceptions of successful providers align with objective measures of the same.

COVID-19 Pandemic Surge: After-Action Report of a Coalition of Emergency Departments in New York City

The coronavirus disease (COVID-19) pandemic has stressed the US health care system in unprecedented ways. In March and April 2020, emergency departments (EDs) throughout New York City experienced high volumes and acuity related to the pandemic. Here, we present a structured after-action report of a coalition of 9 EDs within a hospital system in the New York City metropolitan area, with an emphasis on best practices developed during the prolonged surge as well as specific opportunities for growth. We report our experience in 6 key areas using a framework built around lessons learned. This report represents the most salient concepts related to our institutional after-action report, and those seemingly most relevant to our peer institutions dealing with similar circumstances.

Emergency Department Referral for Hospice and Palliative Care Differs among Patients with Different End-of-Life Trajectories: A Retrospective Cohort Study

Emergency units have been gradually recognized as important settings for palliative care initiation, but require precise palliative care assessments. Patients with different illness trajectories are found to differ in palliative care referrals outside emergency unit settings. Understanding how illness trajectories associate with patient traits in the emergency department may aid assessment of palliative care needs. This study aims to investigate the timing and acceptance of palliative referral in the emergency department among patients with different end-of-life trajectories. Participants were classified into three end-of-life trajectories (terminal, frailty, organ failure). Timing of referral was determined by the interval between the date of referral and the date of death, and acceptance of palliative care was recorded among participants eligible for palliative care. Terminal patients had the highest acceptance of palliative care (61.4%), followed by those with organ failure (53.4%) and patients with frailty (50.1%) (p = 0.003). Terminal patients were more susceptible to late and very late referrals (47.4% and 27.1%, respectively) than those with frailty (34.0%, 21.2%) and with organ failure (30.1%, 18.8%) (p < 0.001, p = 0.022). In summary, patients with different end-of-life trajectories display different palliative care referral and acceptance patterns. Acknowledgement of these characteristics may improve palliative care practice in the emergency department.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Emergency Department Use by Terminally Ill Patients: A Systematic Review

CONTEXT

Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.

OBJECTIVE

To determine the prevalence of TIP visiting the ED.

METHODS

Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I²).

RESULTS

We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37-54%] and 75% in the last six months of life [95% CI 62-83%]; I² = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12-23%]; I² = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping.

CONCLUSIONS

Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department

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.

The Experience of Emergency Department Providers With Embedded Palliative Care During COVID

CONTEXT

Although the importance of palliative care (PC) integration in the emergency department (ED) has long been recognized, few formalized programs have been reported, and none have evaluated the experience of ED clinicians with embedded PC.

OBJECTIVES

We evaluate the experience of ED clinicians with embedded PC in the ED during the coronavirus disease pandemic.

METHODS

ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis.

RESULTS

There were 134 ED clinicians surveyed. About 101 replied (75% response rate). Of those who had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult because of ED volume (5%). About 98% of respondents felt that having PC in the ED was either valuable or very valuable. Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high-quality goal-concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED.

CONCLUSION

ED clinicians' perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.

"So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians

CONTEXT

People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services.

OBJECTIVE

To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations.

METHODS

Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited.

RESULTS

Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable.

CONCLUSIONS

The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.

Cardiopulmonary resuscitation and endotracheal intubation decisions for adults with advance care directive and resuscitation plans in the emergency department

BACKGROUND

Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making.

METHODS

Retrospective audit of electronic patients' medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status.

RESULTS

A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116).

CONCLUSION

Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.

Healthcare providers' views and experiences of non-specialist palliative care in hospitals: A qualitative systematic review and thematic synthesis

BACKGROUND

Healthcare providers working in hospitals are frequently exposed to patients with palliative care needs. For most patients, these reflect non-specialist rather than specialist palliative care needs. Embedding palliative care principles early in patients' disease trajectories within acute care delivery in hospitals, however, is a challenge. How to best understand the experiences of those providing non-specialist palliative care in hospitals has not been systematically assessed.

AIM

To synthesise the evidence on healthcare providers' views and experiences of non-specialist palliative care in hospitals.

DESIGN

A qualitative systematic review and thematic synthesis using Thomas and Harden's thematic synthesis framework.

DATA SOURCES

Databases of MEDLINE, CINAHL, PsycINFO and EMBASE were searched from date of inception to March 2018. Studies were eligible for inclusion if they reported on healthcare providers' views and experiences of non-specialist palliative care in hospitals. Studies were appraised for quality but not excluded on that basis. The review was prospectively registered with the International Prospective Register of Systematic Reviews.

RESULTS

Thirty-nine papers of 37 studies were included, representing 985 hospital healthcare providers' views and experiences. Four major analytical themes emerged; 'Understanding of Palliative Care', 'Complexities of Communication', 'Hospital Ecosystem' and 'Doctors and Nurses - a Different Lens'.

CONCLUSIONS

Non-specialist palliative care in hospitals is operationalised as care in the last weeks and days of life. The organisation of acute care, inter-disciplinary working practices, clinician attitudes, poor communication structures and lack of education and training in palliative care principles exacerbates poor implementation of this care earlier for patients in hospitals.

Emergencies in Pediatric Palliative Care: A Survey of Ambulance Officers to Understand the Interface between Families and Ambulance Services

Background: Pediatric palliative care occurs across contexts through the child's illness trajectory, including within the child or young person's community. Interactions with the ambulance service may occur with a child's deterioration, crisis, or when needing transfer, but there is little research on this interaction. Aim: To explore the experiences and attitudes of ambulance officers in managing pediatric patients with palliative care needs. Design: A targeted e-mail survey was sent exploring perceptions of the involvement with these patients including exposure, comfort, resuscitation topics, and supports available. Setting/Participants: Participants were Queensland ambulance officers known to have had an interaction with one of the last 50 pediatric palliative care referrals across Queensland. Results: Twenty-two survey responses were received. Most of the palliative group accessed ambulances for the 13-month study period. Most ambulance officers did not easily identify patients as receiving palliative care. Many participants felt these cases were challenging, confidence levels varied, and staff counselling services were felt to be relevant. Ambulance officers were most likely to use correspondence provided by the family from their usual team as a guide for emergency management. Half of the participants felt patients receiving pediatric palliative care should have a "not for resuscitation" order. Respondents suggested officer support could be improved through increased patient documentation and promotion of existing officer supports. Conclusions: These findings demonstrate challenges experienced by ambulance officers and suggest practical ways in which pediatric palliative care services can better support emergency services.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Death in the Emergency Department: A Retrospective Analysis of Mortality in a Swiss University Hospital

Acute treatment in emergency medicine revolves around the management and stabilization of sick patients, followed by a transfer to the relevant medical specialist, be it outpatient or inpatient. However, when patients are too sick to be stabilized, i.e., when the care provided in the Emergency Department (ED) may not be sufficient to enable transfer, death may occur. This aspect of emergency medicine is often overlooked, and very few public data exist regarding who dies in the ED. The following retrospective analysis of the mortality figures of a Swiss university hospital from January 1st 2013 to December 31st 2016 attests to the fact that with an incidence of 2.6/1,000, death does occur in the ED. With a broad range of aetiologies, clinical severity at presentation has a high correlation with mortality, a finding that reinforces the necessity of good triage system. Our analysis goes on to show that however (in)frequent death in the ED may be, there exists a lack of advanced directives in a majority of patients (present in only 14.8% of patients during the time of study), a worrying and often challenging situation for Emergency Medicine (EM) teams faced with premorbid patients. Furthermore, a lack of such directives may hinder access to palliative care, as witnessed in part by the fact that palliative measures were only started in 16.6% of patients during the study. The authors hope this study will serve as a stepping stone to promote further research and discussion into early identification methods for patients at risk of death in the ED, as well as motivate a discussion into the integration of palliative care within the ED and EM training curriculum.

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

Background

Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals’ and users’ perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments.

Methods

A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis.

Results

Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care.

Conclusions

This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals

For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.