Corita R. Grudzen

Palliative Care Needs of Seriously Ill, Older Adults Presenting to the Emergency Department

OBJECTIVES The objective was to identify the palliative care needs of seriously ill, older adults in the emergency department (ED). METHODS The authors conducted a cross-sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end-stage liver or renal disease, stroke, oxygen-dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face-to-face interviews were conducted using the Needs Near the End-of-Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well-being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient-clinician relationship, and 9) overall quality of life (QOL). RESULTS Mean (±SD) age was 74.3 (±6.5) years and cancer was the most common diagnosis. Mean (±SD) QOL on the MQOL was 3.6 (±2.9). Over half of the patients exceeded intratest severity-of-needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS. CONCLUSIONS Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs.

Does palliative care have a future in the emergency department? Discussions with attending emergency physicians.

CONTEXT Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams. OBJECTIVES To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED. METHODS Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews. RESULTS Twenty emergency physicians participated (mean age 41 years, range 31-61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine-to provide stabilization of acute medical emergencies-was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physicians responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family. CONCLUSION Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

Condom Use and High-Risk Sexual Acts in Adult Films: A Comparison of Heterosexual and Homosexual Films

OBJECTIVES We compared the prevalence of condom use during a variety of sexual acts portrayed in adult films produced for heterosexual and homosexual audiences to assess compliance with state Occupational Health and Safety Administration regulations. METHODS We analyzed 50 heterosexual and 50 male homosexual films released between August 1, 2005, and July 31, 2006, randomly selected from the distributor of 85% of the heterosexual adult films released each year in the United States. RESULTS Penile-vaginal intercourse was protected with condoms in 3% of heterosexual scenes. Penile-anal intercourse, common in both heterosexual (42%) and homosexual (80%) scenes, was much less likely to be protected with condoms in heterosexual than in homosexual scenes (10% vs 78%; P < .001). No penile-oral acts were protected with condoms in any of the selected films. CONCLUSIONS Heterosexual films were much less likely than were homosexual films to portray condom use, raising concerns about transmission of HIV and other sexually transmitted diseases, especially among performers in heterosexual adult films. In addition, the adult film industry, especially the heterosexual industry, is not adhering to state occupational safety regulations.

The Palliative Care Model for Emergency Department Patients with Advanced Illness

BACKGROUND Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patients subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a providers office. Even for patients in whom goals of care are clear, families often need support for their loved ones physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). DISCUSSION Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition. CONCLUSION Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

Emergency Department–Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial

Importance The delivery of palliative care is not standard of care within most emergency departments (EDs). Objective To compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual. Design, Setting, and Participants A single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization. Interventions Intervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care. Main Outcomes and Measures The primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year. Results A total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice. Conclusions and Relevance Emergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study. Trial Registration clinicaltrials.gov Identifier: NCT01358110.

Integration of palliative care into emergency medicine: The Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration

BACKGROUND Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. CASE REPORT We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. DISCUSSION We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. CONCLUSION The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.

Characteristics of Emergency Department Patients Who Receive a Palliative Care Consultation

BACKGROUND A large gap exists between the practice of emergency medicine and palliative care. Although hospice and palliative medicine has recently been recognized as a subspecialty of emergency medicine, few palliative care teams routinely interact with emergency providers, and primary palliative care skills among emergency providers are lacking. OBJECTIVE To identify the proportion and characteristics of patients who receive a palliative care consultation and arrive via the emergency department (ED). METHODS A descriptive study of adult ED patients from an urban, academic tertiary care hospital who received a palliative care consultation in January 2005 or January 2009. RESULTS In January 2005, 100 of the 161 consults (62%) arrived via the ED versus 63 of 124 consults (51%) in January 2009 (p=0.06). Mean days from admission to consultation in January 2005 were six days (standard deviation 11), versus nine days (SD 26) in January 2009 (p=0.35). Three of the 100 consultations (3%) in January 2005 were initiated in the ED, versus 4 of the 64 (6%) in January 2009. CONCLUSIONS At an urban academic medical center with a well-developed palliative care service, the majority of palliative care consultations were for patients who arrive via the ED. Despite this, only a small minority of consultations originated from emergency providers and consultation was on average initiated days into a patients hospital stay.

I want to be taking my own last breath: patients' reflections on illness when presenting to the emergency department at the end of life.

OBJECTIVE To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life. METHODS Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results. RESULTS Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences. CONCLUSIONS Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field

OBJECTIVES The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest. METHODS Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances. RESULTS Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role. CONCLUSIONS Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.

Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review.

CONTEXT Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects. OBJECTIVES To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED. METHODS Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. RESULTS Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral. CONCLUSION We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.