Heather Lane

Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians

Patients with cancer are presenting to emergency departments (ED) for end‐of‐life care with increasing frequency. Little is known about this experience for patients and ED clinicians in Australia.

Caught in the middle: tensions around the emergency department care of people with advanced cancer.

People with advanced cancer frequently present to hospital EDs. International studies report conflicting attitudes towards providing such care and difficulties with communication. The experience of Australian clinicians, however, is not described.

What’s in a name? A qualitative exploration of what is understood by “palliative care” in the emergency department:

Background: The understanding of what palliative care is, and which patients may benefit from palliative care, has important implications for optimal patient care in all areas of health provision. Aim: To explore the understanding of palliative care by healthcare professionals caring for patients with advanced cancer attending emergency departments. Design: Qualitative study, with two phases: the first, a series of focus groups with healthcare professionals from various disciplines and settings caring for patients with advanced cancer presenting to emergency departments; the second, semi-structured telephone interviews with emergency healthcare professionals across Australian States and Territories, including outside metropolitan centers. The data were audio-recorded and transcribed, with analysis undertaken using a qualitative thematic analysis. Setting/participants: Saturation of themes was reached after 8 focus groups (22 emergency nurses, 21 emergency physicians, 6 oncologists, 6 hospital palliative care clinicians, and 28 community palliative care clinicians) and 11 telephone interviews (8 emergency physicians and 3 emergency nurses), a total of 94 participants. Results: The overarching theme was that healthcare professionals held contradictory understandings of palliative care and its application in the emergency department; subthemes highlighted these inconsistencies when the term “palliative” is used, in understandings of and engagement with palliative care services and in perceptions about the practical utility of palliative care. Conclusion: There are entrenched contradictions and tensions surrounding the term “palliative care”; confronting these is likely to require more than re-branding, and will promote better care for this vulnerable patient group in the emergency department.

Managing the advanced cancer patient in the Australian emergency department environment: findings from a national survey of emergency department clinicians.

BackgroundDelivery of care to people with advanced cancer in the emergency department (ED) is complicated by competing service demands, workloads and physical design constraints. We explored emergency clinicians’ attitudes to the ED environment when caring for patients who present with advanced cancer, and how these attitudes are affected by access to palliative care services, palliative care education, staff type, ED experience and patient demographic, hospital type and region.MethodsWe electronically surveyed clinicians from the College of Emergency Nursing Australasia, Australian College of Emergency Nursing and Australasian College for Emergency Medicine working in an Australian ED.ResultsRespondents were 444 doctors and 237 nurses. They reported overcrowding, noise, lack of time and privacy as barriers to care. Most (93.3%) agreed/strongly agreed that the dying patient should be allocated private space in ED. 73.6% (451) felt unable to provide a desired level of care to advanced cancer patients in ED. Clinician attitudes were affected by staff type, experience, ED demographic and hospital type, but not education in palliative care.ConclusionsED environments place pressure on clinicians delivering care to people with advanced cancer. Integrating palliative care services in ED and redesigning EDs to better match its multifaceted functions should be considered.

The war against dementia: are we battle weary yet?

Recently, the use of military metaphors when discussing dementia and in particular Alzheimers disease has increased, both in medical literature and mainstream media. While military metaphors are a recent adoption when used to describe dementia, in oncology there has been longstanding debate about the usefulness of such metaphors. This article reviews the history of military metaphors in medicine, literature discussing their use, and considers their use in describing dementia. While military metaphors are widely used in medicine, consideration should be taken in their use as they have the potential to influence the way we and our patients conceptualise and experience illness and treatment.

Hospitalisation of high-care residents of aged care facilities: are goals of care discussed?

Residents of residential aged care facilities (RACF) are commonly hospitalised towards the end of life. Determining the hospitalisation experiences, including the discussion of goals of treatment, is essential to best plan care including planning for end‐of‐life care for this population.

Ideal care and the realities of practice: interdisciplinary relationships in the management of advanced cancer patients in Australian emergency departments

PurposeOver the course of their illness, a person with cancer is likely to see a number of different healthcare professionals, including those in the emergency department (ED). There is limited research examining the interaction and communication between the involved healthcare professionals when such a patient presents to the ED. This study aimed to explore the views and experiences of interdisciplinary interactions of healthcare professionals caring for patients with advanced cancer who present to the ED.MethodsFocus groups and semistructured interviews were conducted with clinical staff working in ED, oncology and community and hospital-based palliative care services. Interviews and focus groups were recorded and transcribed verbatim. Thematic analysis was undertaken by three researchers independently. These themes were then discussed by the wider team and consensus reached on themes and subthemes.ResultsEighty-three healthcare professionals participated in focus groups, and 11 were interviewed. The over-arching theme to emerge was one of a conflict between ideal care and the realities of practice, particularly arising where clinicians from different services were required to work together to provide care. This idea was further understood through a series of subthemes including communication, decision-making and understanding of other services.ConclusionsParticipants articulated agreed upon ideals of optimal care for advanced cancer patients across all three services, however there was frequently discord between these ideals and the actual care provided. Service demands and the day-to-day stressors of practice appeared to influence people’s actions and engender conflict

Managing expectations: Providing palliative care in aged care facilities.

To explore the views and experiences of staff from RACFs and community palliative care services (CPCSs) on providing palliative and end‐of‐life care in RACFs.

Is geriatric assessment being incorporated into general oncology

A growing group of clinicians believe in the value of geriatric assessment (GA) in theevaluationof theolder adultswith cancer. Most commonly, GA is a conglomeration of assessment tools which are aggregated to give the treating clinician an indication of the fitness of the patient. Less frequently, a GA is performed by a geriatrician. The incorporation of GA into routine practice, however, has occurred in relatively few centers internationally. Even amongst centers with GA in oncology, the impact on decision making or clinical outcomes is yet to be defined. In a recent article published in this journal, Decoster et al. describe a large and important study examining the influence of GA on the treatment decisions of medical oncologists in a heterogeneous group of older patients with cancer. The GA results were available to the clinicians, who were then asked: whether they reviewed the GA prior to making their treatment decision, if they had modified the treatment compared to standard therapy, and whether the GA influenced this treatment decision. Using predefined geriatric risk criteria, almost three quarters of patients were defined as ‘at risk’. The influence of clinical assessment on treatment modification corresponded poorly to those identified as ‘at risk’: 34% of ‘fit’ patients did not receive standard treatment, whilst 55% of those ‘at risk’ were given standard treatment. Furthermore, despite all patients having a GA, this assessment was only consulted in 56% of patients, andof these patients, theGAonly influenced treatment decisions in 6%. These results are not surprising— in a similar study, Kenis et al. found that only 61% of the GA were reviewed prior to making treatment decisions, and of these patients, the GA influenced treatment decisions in only 25%. This was despite theGA yielding additional information over clinical assessment in 62% of the cases. McCleary et al. developed a computerized version of a self-reportedGAwhichwas found beneficial by 75% of clinicians, however almost all clinicians felt that the GA would not influence current or future treatment plans. GA also did not change oncological management in a pilot study by Aparicio et al. In contrast, GA by a geriatrician followed by an oncogeriatric multidisciplinary discussion altered cancer management in 21–39%, with a higher rate of alterations (49%) when older patients with complexity were targeted.

Skills, expertise and role of Australian emergency clinicians in caring for people with advanced cancer

Objectives To explore the views of Australian emergency department (ED) clinicians about their skills, role and expertise in caring for people with advanced cancer. Methods A cross-sectional electronic survey of doctors and nurses working in Australian EDs was undertaken. Comparisons were made by demographics and whether respondents had received palliative care education. Results The sample comprised 444 doctors (response rate 13.5%), the majority Fellows (emergency medicine specialists) of the Australasian College for Emergency Medicine, and 237 nurses, from all states, territories and regions (metropolitan and regional). A minority (n=123, 20.6%) felt that the ED was not an appropriate place for patients with advanced cancer to present for acute care, while almost two-thirds (n=397, 64.8%) found caring for such patients rewarding, particularly nurses and those who had received palliative care education; very few (n=40, 6.5%) reported feeling uncomfortable talking to the families of dying patients. A minority (n=129, 21.0%) felt that it was not appropriate for junior medical staff to assess these patients, nurses much more than doctors (42.9% vs 8.5%, p<0.001). Over half (n=338, 55.1%) felt sufficiently skilled in managing pain for people with advanced cancer, with Fellows, more experienced doctors, and those who had received palliative care education more likely to feel skilled. Conclusions ED clinicians in Australia, particularly those who have received palliative care education, feel comfortable and adequately skilled in managing people with advanced cancer presenting to EDs, and most find it rewarding. The importance of palliative care education to emergency clinicians’ training should be recognised.