The Integration of Palliative Care into the Emergency Department

Palliative care in the emergency department: An observational study of doctors in KwaZulu-Natal

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.

Emergency department hospice care pathway associated with decreased ED and hospital length of stay

INTRODUCTION

While increasing evidence shows that hospice and palliative care interventions in the ED can benefit patients and systems, little exists on the feasibility and effectiveness of identifying patients in the ED who might benefit from hospice care. Our aim was to evaluate the effect of a clinical care pathway on the identification of patients who would benefit from hospice in an academic medical center ED setting.

METHODS

We instituted a clinical pathway for ED patients with potential need for or already enrolled in hospice. This pathway was digitally embedded in the electronic health record and made available to ED physicians, APPs and staff in a non-interruptive fashion. Patient and visit characteristics were evaluated for the six months before (05/04/2021-10/4/2021) and after (10/5/2021-05/04/2022) implementation.

RESULTS

After pathway implementation, more patients were identified as appropriate for hospice and ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 h. Social work consultation for hospice evaluation increased, and more patients were discharged from the ED with hospice. As more patients were identified with end-of-life care needs, the number of patients admitted to the hospital increased. However, more patients were admitted under observation status, and admission LOS decreased by a median of 18.4 h.

CONCLUSION

This non-interruptive, digitally embedded clinical care pathway provided guidance for ED physicians and APPs to initiate hospice referrals. More patients received social work consultation and were identified as hospice eligible. Those patients admitted to the hospital had a decrease in both ED and hospital admission LOS.

Palliative Home Visit Intervention and Emergency Admission in Pediatric Cancer Children: A Randomized Controlled Trial

Palliative care model can be carried out at home, in the community, or in long-term home care. Home visits in palliative care have an important role in providing continuity of care and psychosocial support to both the patient and their parents/caretakers. This study is aimed to determine the impact of home visit program to the frequency of emergency room (ER) admissions in children with cancer.

METHODS

Randomized controlled trial of 60 pediatric patients with malignancies who were given palliative care (a 3-months home visit) and those who were not was conducted. Patients were children with cancer aged 2-18 years old. Emergency room admissions from the last three months were recorded before patients were enrolled. A two-way communication between a trained health worker and patients with or without their parents were conducted as the intervention. Interventions were given in six sessions (1 session every 2 weeks). During study period, ER admissions were recorded further. Data was analyzed using bivariate analysis, OR calculations were performed.

RESULTS

In the intervention group, 11 children (36.7%) had fewer ER admissions, while 4 (13.3%) had more and 15 children (50%) had constant ER admissions, respectively. Meanwhile, only 2 children (7.7%) were found to have fewer ER admissions in the control group. Others in this group have varying results, 11 children (42.3%) were found to have more admissions to the ER and 13 children (50%) had constant ER admissions. In the intervention group, ER admissions were reduced by 10 visits, while in the control group, the admissions were increased by 16 visits (OR 4.77, 95% CI 1.29-17.65; p = 0.018).

CONCLUSION

Palliative home visit provides care matched to patient and family needs, trained parents to be skillful in managing child, and enabling avoidance of unnecessary hospitalizations (4.7 times).

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.

Home-based Palliative Intervention to Improve Quality of Life in Children with Cancer: A Randomized Controlled Trial

OBJECTIVE

Over the past few years, an integrated approach of palliative care (PC) to chronic and/or life-threatening conditions care has been widely used. Home-based PC (HBPC) service is developed to meet the needs of patients at home; however, it has not been used widely. This study is aimed at determining the benefits of integrated HBPC for the quality of life (QoL) and symptoms intensity in Indonesian children with malignancies.

METHOD

A randomized controlled trial was carried out to compare the quality of life between patients who were given PC (a three-month home visit) and those who did not receive PC (control group). Each group was constituted of thirty children with cancer and aged 2-18 years old and were consulted by a palliative team. The participants were randomly allocated to two groups. In the first and twelfth weeks of the intervention, all patients were assessed using the Pediatric Quality of Life Inventory (PedsQLTM) questionnaire cancer module 3.0 (report by proxy or self-report). Symptoms intensity (pain, anorexia, sleep disturbance) were scored by using Edmonton Symptoms Assessment Scale (ESAS). The mean score and each dimension score of both groups were compared and analyzed using bivariate analysis.

RESULTS

In total, fifty participants were included in the study. A significant difference was found between the two groups in terms of the mean total score in control group 62.39 and intervention group 81.63 (p<0.001). The QoL was improved in the intervention group, while it was declined in the control group as the disease progressed. The main improvements were in the pain and nausea aspects (p<0.001), followed by procedural anxiety (p=0.002), treatment anxiety (p=0.002), and worry (p=0.014). Palliative intervention significantly reduced sleep disturbances (p=0.003) and anorexia (p<0.001).

CONCLUSION

Home-based PC improved several aspects of QoL and caused better symptom management in children with malignancies. An early intervention concurrent with the underlying treatment can improve QoL in these children.

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.

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

Background:

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

Aims:

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

Methods:

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

Results:

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

Conclusions:

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

Nurses Training and Capacitation for Palliative Care in Emergency Units: A Systematic Review

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.

Determination of the characteristics and outcomes of the palliative care patients admitted to the emergency department

OBJECTIVES

Terminally ill patients in need of palliative care present to emergency departments. This study aims to identify the usage level of the emergency departments by patients in need of palliative care, along with their experienced symptoms, preferences, needs, and the subsequent initiatives taken for symptom management.

METHODS

The study was designed as a cross-sectional study and conducted with a group of 208 patients. The Patient Information Form, the Form of the Criteria for Receiving Palliative Care, and the Karnofsky Performance Scale were used for data collection.

RESULTS

This report founda thatcancer patients were the most frequent users of emergency facilities within palliative care patient groups and more than half of those hospitalized patients were subsequently admitted to intensive care units. Patients with poorer functional conditions and in need of further palliative care preferred home care rather than receiving Advanced Cardiac Life Support.

CONCLUSION

This study displays evidence that palliative care patients with a poorer functional condition in need of further palliative care should be able to spend the last days of their lives at home with their families rather than in the exhausting and crowded environment of the emergency departments. Furthermore, healthcare policymakers should actively support palliative care as well as taking the necessary actions to mitigate the burden placed on hospital resources.

A retrospective study on end-of-life care in the emergency department of a tertiary hospital in Singapore

Introduction:

The emergency department receives a whole breadth of patient types. Those who are imminently dying may attend the emergency department in the hours or days leading up to their demise, necessitating the initiation of end-of-life care in the emergency department.

Aim:

The aim of our study was to describe the characteristics and management of imminently dying patients who had presented to our emergency department to identify opportunities for improvement in the provision of end-of-life care in the emergency department.

Methods:

A retrospective study involving patients who died in the emergency department within 48 hours of registration presenting between 1 January 2018 and 31 December 2018 was carried out.

Results:

Out of 59 included patients, 91.5% had pre-existing medical conditions; 25.4% had end-stage organ failure of which renal and cardiac were most common. Only 15.3% had preferred care plans documented and among these, only a minority (33.3%) had undergone formal advance care planning. The most common presenting symptom among patients who died within 48 hours was dyspnoea (44.1%). The most common investigation done was capillary blood glucose (84.7%) and the most common procedure was an intravenous peripheral cannula insertion (84.7%). Antibiotics were given in 30.5% of the patients and fentanyl was administered in 20.3% for symptom control.

Conclusion:

The majority of patients presenting to the emergency department within hours or days of their demise had pre-existing chronic or terminal conditions but only a few had specified their preferences for end-of-life care. Investigations and procedures that do not affect patient comfort or outcomes should be minimised.

Management of oncology-related emergencies at the emergency department: A long-term undertaking

Background:

The emergency department at the Singapore General Hospital is an emergency department with an annual census of 140,000 and oncology-related attendances of about 4000 (2.8%). These patients are often admitted for further care. Palliative care in the emergency department for these patients is often minimal. The aim of this study was to determine the state of current management of oncology-related emergencies at the Singapore General Hospital’s emergency department, hence identifying specific areas for intervention.

Methods:

We carried out a retrospective data review of all Singapore General Hospital’s emergency department patients who had either cancer-related diagnoses or were admitted to the Medical Oncology Department in October 2018. Simple statistical analysis was then performed using IBM SPSS version 21.

Results:

Of 308 identified patients, there was approximately equal distribution by sex. The women were generally younger than the men (61.33 ± 13.63 years vs 67.36 ± 12.02 years, p = 0.063, confidence interval −8.94 to −3.13). Seventy-two (23.4%) of the patients arrived at emergency department by ambulance. The mean emergency department length of stay was 4.25 h. About half of the patients had either lung, colorectal, or breast as their primary site of cancer. There was no correlation between clinical severity according to the National Early Warning Scores and triage complaint-type or emergency clinical diagnosis. More than 90% were admitted, with about 32.6% dying during their inpatient stay. High National Early Warning Scores were significantly associated with mortality.

Conclusion:

There is large potential for interventions to improve patient well-being in the pre-hospital setting and emergency department. Given the sizable number of patients with poor outcomes, palliative care is also of paramount importance.

Emergency department staff priorities for improving palliative care provision for older people: A qualitative study

BACKGROUND

Emergency department-based palliative care services are increasing, but research to develop these services rarely includes input from emergency clinicians, jeopardizing the effectiveness of subsequent palliative care interventions.

AIM

To collaboratively identify with emergency clinicians' improvement priorities for emergency department-based palliative care for older people.

DESIGN

This was one component of an experience-based co-design project, conducted using semi-structured interviews and feedback sessions.

SETTING/PARTICIPANTS

In-depth interviews with 15 emergency clinicians (nurses and doctors) at a large teaching hospital emergency department in the United Kingdom exploring experiences of palliative care delivery for older people. A thematic analysis identified core challenges that were presented to 64 clinicians over five feedback sessions, validating interview findings, and identifying shared priorities for improving palliative care delivery.

RESULTS

Eight challenges emerged: patient age; access to information; communication with patients, family members, and clinicians; understanding of palliative care; role uncertainty; complex systems and processes; time constraints; and limited training and education. Through feedback sessions, clinicians selected four challenges as improvement priorities: time constraints; communication and information; systems and processes; and understanding of palliative care. As resulting improvement plans evolved, "training and education" replaced "time constraints" as a priority.

CONCLUSION

Clinician priorities for improving emergency department-based palliative care were identified through collaborative, iterative processes. Though generally aware of older palliative patients' needs, clinicians struggled to provide high-quality care due to a range of complex factors. Further research should identify whether priorities are shared across other emergency departments, and develop, implement, and evaluate strategies developed by clinicians.

Experiences of healthcare professionals in providing palliative end-of-life care to patients in emergency departments: a systematic review protocol

The objective of this review is to identify and synthesize the best available evidence on the experiences of healthcare professionals in providing palliative care to patients at the end of life in emergency departments.