Jennifer Weil

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.

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

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.

The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study

Background: Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients’ perceptions of hospital Emergency Department presentations. Aim: To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers. Design: Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame. Setting/participants: In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed. Results: Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options. Conclusion: Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Assessment of potential opioid toxicity and response to naloxone by rapid response teams at an urban Melbourne hospital: Brief Communications

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18‐month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

A tertiary hospital audit of the use of medical imaging in the 24 h preceding death.

This study aims to investigate the number, modality and indication for imaging studies performed on acute hospital inpatients in the 24 h prior to death. Data were obtained from retrospective analysis of deceased patients from a university affiliated tertiary hospital over a 2‐year period and it was found that around one in five inpatients received medical imaging in the last 24 h of their life (364 of 1855, 19.6%).