Sangeeta Lamba

Hospice Care and the Emergency Department: Rules, Regulations, and Referrals

Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care. Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals. This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department.

Self‐reported non‐adherence to immune‐suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors

Lamba S, Nagurka R, Desai KK, Chun SJ, Holland B, Koneru B. Self‐reported non‐adherence to immune‐suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01489.x. 
© 2011 John Wiley & Sons A/S.

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.

Palliative Medicine and Geriatric Emergency Care:: Challenges, Opportunities, and Basic Principles

Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.

Demonstrations of Clinical Initiatives to Improve Palliative Care in the Emergency Department: A Report From the IPAL-EM Initiative

STUDY OBJECTIVE We describe 11 clinical demonstrations of emergency department (ED) and palliative care integration to include traditional consultation services with hospital-based palliative care consultants through advanced integration demonstrations in which the ED provides subspecialty palliative care practice. METHODS An interview guide was developed by the Improving Palliative Care in Emergency Medicine board that consists of emergency clinicians and palliative care practitioners. Structured interviews of 11 program leaders were conducted to describe the following key elements of the ED-palliative care integration, to include structure, function, and process of the programs, as well as strengths, areas of improvement, and any tools or outcome measures developed. RESULTS In this limited number of programs, a variety of strategies are used to integrate palliative care in the ED, from traditional consultation to well-defined partnerships that include board-certified emergency clinicians in hospice and palliative medicine. CONCLUSION A variety of methods to integrate palliative care in the emergency setting have emerged. Few programs collect outcomes-based metrics, and there is a lack of standardization about what metrics are tracked when tracking occurs.

Emergency-department-initiated palliative care consults: a descriptive analysis.

BACKGROUND To provide optimal palliative care (PC) services in the acute setting of the emergency department (ED), it may be beneficial for the consult team to delineate the most commonly requested ED-PC services and understand why ED clinicians currently request palliative care consults (PCC). METHODS Using a retrospective review of data gathered by the PC team on services and consults we studied patterns of ED-initiated PCC (EDI-PCC) and describe here the use of PC services in an urban tertiary-care-center ED. We then compare these with PC services provided in the traditional in-patient consult setting. RESULTS AND CONCLUSIONS EDI-PCC patients are young, likely secondary to traumatic and critical, sudden events. In-hospital mortality rate for EDI-PCC patients is very high (most die early and in the ED setting), signifying a trend for ED clinicians to request PC consults in those who are imminently dying. PC consult teams called to the ED should expect to provide high-priority, time-sensitive services and anticipate a high level of bereavement/emotional support for distraught and unprepared families, with major discussions around end-of-life care.

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.

Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department

CONTEXT Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. OBJECTIVES To determine the rate of advance care planning in older adults presenting to the emergency department (ED) and translation into medical directives in the electronic medical record (EMR). METHODS A convenience sample of adults 65 years or older was recruited from a large urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. RESULTS From February 2012 to May 2013, 53.8% (367 of 682) of older adults who completed the survey in the ED reported having a health care proxy, and 40.2% (274 of 682) had a living will. Of those admitted to the hospital, only 4% (4 of 94) of patients who said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5 of 115) of patients who had a health care proxy had the persons name or contact information documented in their medical record. CONCLUSION About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR.

Integrating palliative care in the out-of-hospital setting: Four things to jump-start an EMS-palliative care initiative

Abstract Emergency medical service (EMS) is frequently called to care for a seriously ill patient with a life-threatening or life-limiting illness. The seriously ill include both the acutely injured patients (for example in mass casualty events) and those who suffer from advanced stages of a chronic disease (for example severe malignant pain). EMS therefore plays an important role in delivering realistic, appropriate, and timely care that is consistent with the patients wishes and in treating distressing symptoms in those who are seriously ill. The purpose of this article is to; 1) review four case scenarios that relate to palliative care and may be commonly encountered in the out-of-hospital setting and 2) provide a road map by suggesting four things to do to start an EMS-palliative care initiative in order to optimize out-of-hospital care of the seriously ill and increase preparedness of EMS providers in these difficult situations. Key Words: Collaboration; emergency medical service; integration; out of hospital; palliative care

Music Reduces Patient Anxiety During Interfacility Ground Critical Care Transport

INTRODUCTION Interfacility ground critical care transport (CCT) of patients by ambulance may be stressful. This study evaluated whether playing music during CCT reduces patient anxiety and whether objective evidence is manifested by a change in vital signs. SETTING Urban teaching hospital. METHODS In this prospective cohort study, music was played for eligible adult patients during CCT while recording vital signs. A questionnaire was subsequently mailed to patients to rate whether the ambulance transport was stressful, the impact music had on transport, whether music changed their anxiety, whether music made them comfortable and relaxed, and whether they would prefer music to be played on future transports. Vital signs were compared between respondents who perceived transport as stressful and those who did not. RESULTS One hundred two patients were enrolled; 23 respondents (22.5%) constituted the study group. Four patients (17.4%) reported CCT as stressful (average response, 4.75). Nineteen (82.6%) rated CCT as not stressful (average response, 1.63). Subjectively, patients reported a positive impact of music on transport, with improved comfort and relaxation but only a minimal decrease in anxiety. No statistically significant change in vital signs was observed between cohorts; too few patients were enrolled to generate power to detect any difference. CONCLUSIONS Music therapy is a simple adjunct for use during CCT that may increase patient comfort and alleviate anxiety. The small number of patients in this preliminary report limits the strength of any conclusions. Larger studies are needed.