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Tiah L, Chua MT, Kuan WS, Tan A, Tay E, Yash Pal R, Dong C. Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis. Medicina (B Aires) 2023; 59:medicina59030456. [PMID: 36984457 PMCID: PMC10053832 DOI: 10.3390/medicina59030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
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Affiliation(s)
- Ling Tiah
- Accident & Emergency Department, Changi General Hospital, Singapore Health Services, Singapore 529889, Singapore
- Correspondence:
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Alina Tan
- Department of Anesthesia, National University Hospital, National University of Singapore, Singapore 119074, Singapore
| | - Eileen Tay
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Chaoyan Dong
- Education Office, Sengkang General Hospital, Singapore Health Services, Singapore 554886, Singapore
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Bayuo J, Agbeko AE, Acheampong EK, Abu-Odah H, Davids J. Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes. Acad Emerg Med 2022; 29:1357-1378. [PMID: 35435306 DOI: 10.1111/acem.14508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/22/2022] [Accepted: 04/14/2022] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | | | | | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Jephtah Davids
- College of Health Science, University of Ghana, Legon, Greater Accra, Ghana
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3
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Kirkland SW, Yang EH, Garrido Clua M, Kruhlak M, Campbell S, Villa-Roel C, Rowe BH. Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review. Acad Emerg Med 2022; 29:1229-1246. [PMID: 35344239 DOI: 10.1111/acem.14492] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED). METHODS A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs). RESULTS A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%. CONCLUSIONS This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Garrido Clua
- Department of Orthopaedic Surgery, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Maureen Kruhlak
- School of Veterinary Medicine, St. George's University, West Indies, Grenada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Grudzen CR, Barker PC, Bischof JJ, Cuthel AM, Isaacs ED, Southerland LT, Yamarik RL. Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician. EMERGENCY CANCER CARE 2022; 1:10. [PMID: 35966217 PMCID: PMC9362452 DOI: 10.1186/s44201-022-00010-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.
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Kim JS, Lee SY, Lee MS, Yoo SH, Shin J, Choi W, Kim Y, Han HS, Hong J, Keam B, Heo DS. Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea. Palliat Care 2022; 21:105. [PMID: 35668487 PMCID: PMC9170493 DOI: 10.1186/s12904-022-00988-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Jung Sun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Jeongmi Shin
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyung Sook Han
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jinui Hong
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Dae Seog Heo
- Patient-Centered Clinical Research Coordinating Center, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
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End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review. Int Emerg Nurs 2022; 61:101153. [PMID: 35240435 DOI: 10.1016/j.ienj.2022.101153] [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: 10/05/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022]
Abstract
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.
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Crock B, Islam MR, Subramaniam S. Emergency Department Utilisation by Palliative Patients in a Regional Australian Setting. Am J Hosp Palliat Care 2021; 39:956-961. [PMID: 34866425 DOI: 10.1177/10499091211055903] [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: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Ben Crock
- 72544Goulburn Valley Health, Shepparton, Victoria, Australia
| | - Md Rafiqul Islam
- 72544Goulburn Valley Health, Shepparton, Victoria, Australia.,Department of Rural Health, The University of Melbourne, Shepparton, Victoria, Australia.,Rural Health School, College of Science, Health and Engineering, La Trobe University, Shepparton, Victoria, Australia
| | - Sivakumar Subramaniam
- 72544Goulburn Valley Health, Shepparton, Victoria, Australia.,Department of Rural Health, The University of Melbourne, Shepparton, Victoria, Australia
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Denney CJ, Duan Y, O'Brien PB, Peach DJ, Lanier S, Lopez J, Buxton D, Maulfair M, Kuhlman J, Ahmad S, Helmstetter K. An Emergency Department Clinical Algorithm to Increase Early Palliative Care Consultation: Pilot Project. J Palliat Med 2021; 24:1776-1782. [PMID: 34015232 DOI: 10.1089/jpm.2020.0750] [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: 11/13/2022] Open
Abstract
Introduction: The emergency department (ED) is a primary entry point of hospitals but does not have a system to identify and consult palliative care (PC) early in patients who meet criteria. Objectives: To determine the measurable effects of an ED PC consultation on patients who meet criteria, hypothesizing that ED PC consultation would lead to decreased average length of stay (ALOS), average direct cost per patient, decreased number of surgeries, and radiological tests performed per patient. Materials and Methods: A physician-led data-driven evidence-based algorithm was designed and piloted with implementation in two hospitals during January-March 2019 in Orlando, FL. A retrospective review of health record data was completed, comparing patients receiving PC consultation ordered in the ED versus those ordered after admission. Results: ED patients (n = 662) met PC criteria. PC consultation was ordered in ED for 80 (12.1%) cases. The following outcomes were lower for patients who received ED PC consultation than those who did not: ALOS by 6.4 days (6.74 vs. 13.14 days; p < 0.001), in-hospital mortality (12.5% vs. 19.1%; p = 0.11), surgery (11% vs. 37%; p < 0.01), radiological tests per patient (4.01 vs. 10.57; p < 0.001), and average direct cost per patient ($7,193 vs. $22,354). However, 30-day hospital revisit rates were relatively higher in those who did receive ED PC consultation than those who did not (20% vs. 13% p = 0.15). Conclusions: In this pilot project, PC patients can be identified in the ED with an algorithm that leads to earlier consultation and improved patient outcomes. Larger research trials are needed to replicate this strategy and results.
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Affiliation(s)
- Clifford J Denney
- Department of Emergency Medicine, AdventHealth Orlando, Orlando, Florida, USA
| | - Yuchen Duan
- Department of Emergency Medicine, AdventHealth Orlando, Orlando, Florida, USA
| | - Paul B O'Brien
- Department of Emergency Medicine, AdventHealth Orlando, Orlando, Florida, USA
| | - Daniel J Peach
- Department of Clinical Innovation, AdventHealth Orlando, Orlando, Florida, USA
| | - Shelley Lanier
- Department of Clinical Innovation, AdventHealth Orlando, Orlando, Florida, USA
| | - Joshua Lopez
- Department of Clinical Innovation, AdventHealth Orlando, Orlando, Florida, USA
| | - David Buxton
- Department of Palliative Care, AdventHealth Orlando, Orlando, Florida, USA
| | - Mitchell Maulfair
- Department of Emergency Medicine, AdventHealth Orlando, Orlando, Florida, USA
| | - Jeffrey Kuhlman
- Department of Clinical Innovation, AdventHealth Orlando, Orlando, Florida, USA
| | | | - Kyle Helmstetter
- Department of Emergency Medicine, AdventHealth Orlando, Orlando, Florida, USA
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Poi CH, Koh MYH, Ong WYM, Wong YL, Yow FC, Tan HL. The challenges of establishing a palliative care collaboration with the intensive care unit: How we did it? A prospective observational study. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1852655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Choo Hwee Poi
- Palliative Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Mervyn Yong Hwang Koh
- Palliative Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
- Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | | | - Yu-Lin Wong
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Hui Ling Tan
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
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Nurses Training and Capacitation for Palliative Care in Emergency Units: A Systematic Review. ACTA ACUST UNITED AC 2020; 56:medicina56120648. [PMID: 33256039 PMCID: PMC7759785 DOI: 10.3390/medicina56120648] [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: 09/07/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022]
Abstract
Background and objectives: Palliative care (PC) prevents and alleviates patients´ suffering to improve their quality of life in their last days. In recent years, there has been an increase in visits to the emergency services (ES) by patients who may need this type of care. The aims were to describe the training and capacitation of nurses from ES in PC. Accordingly, a systematic review was performed. Materials and Methods: Medline, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were used. The search equation was “Palliative care and nursing care and emergency room”. A total of 12 studies were selected. Results: The studies agree on the need for training professionals in PC to provide a higher quality care, better identification of patient needs and to avoid unnecessary invasive processes. Similarly, the implementation of a collaborative model between ES and PC, the existence of a PC specialized team in the ES or proper palliative care at home correspond to a decrease in emergency visits, a lower number of hospitalizations or days admitted, and a decrease in hospital deaths. Conclusions: The development of PC in the different areas of patient care is necessary. Better palliative care leads to a lower frequency of ES by terminal patients, which has a positive impact on their quality of life. Access to PC from the emergency unit should be one of the priority health objectives due to increment in the aged population susceptible to this type of care.
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