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Themes, sub-themes and representative quotations from qualitative analysis (Continued)
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Background:
Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating...
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Citations
... Despite these contextual, structural and individual elements that slow down the implementation of a palliative care approach in EDs, several roles of ED caregivers were highlighted through the use of clinical Like in other studies, ED caregivers endorse the investigator role to achieve the management of acute illnesses and distressing palliative symptoms like dyspnea or pain for older patients with a palliative pro le, but ED caregivers expressed the need for therapeutic alternatives to their usual medication (24,41). Nonetheless, their role in realising an entire advanced care planning does not seems to meet the ED caregivers skills, nor the right timing, nor the best environment, as also explained by other studies (24,42). ...
... Particular attention must be paid to elements that can ensure the continuity of care within the model implemented and adapted to the local context of care. These elements include collaborative processes, communication between caregivers from different sectors, and prede ned pathways (41,45). ...
Background
Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED’s role in providing palliative care for this population.
Methods
We designed a qualitative study based on 1) interviews – conducted with older patients (≥75 years) with a palliative profile and their informal caregivers – and 2) focus groups – conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis.
Results
Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is a widespread discomfortwith caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients’(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED’s role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. Their main perspective is that ED caregivers could be the identifiers of early palliative profile.
Conclusions
Even if there are still major obstacles to implementing palliative care for older patients upon admission to the emergency department, ED caregivers already assume certain roles, although they do not recognise them as such. In the future, ED caregivers might also endorse the role of early identifier.
... Organizational barriers include a lack of educational training and insufficient support systems [1,2,4]. Patients reported perceiving the ED as a noisy and inhospitable environment and identified a lack of communication skills as significant obstacles to receiving quality care [1,5]. ...
... The interview questions were developed through an iterative process, from a literature review [18][19][20][21][22] and research studies previously conducted by the team on end-of-life care in the ED [23,24]. The questions aimed to elicit participants' perceptions about end-oflife care in the ED, such as positive experiences, challenges, barriers, and suggestions for improvement. ...
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
... 13,48 In these pandemic phases, there was more action and less reflection; this was also due to ED professionals' tendency to intervene immediately. 49 In many cases, the PC team who worked in emergency settings showed more coping mechanisms and reduced emotional distress in managing end-of-life experiences than their colleagues from other wards and specialities. 50,51 This also is reflected in the ability of PC teams to manage ethical conflicts regarding end-of-life treatment decisions of the most critical COVID patients. ...
... [53][54][55] Therefore, a cultural change is needed, and the experience during the two pandemic waves could trigger the willingness to integrate elements of palliation into emergency settings. 49,56,57 The pandemic in Italy, especially in the first wave, with many poor diagnoses, challenged medicine's purposes, suggesting that health professionals could not work on traditional healing anymore 48,58 but should embrace a different approach. A PC team could have helped to activate such reflection on the failed mission of health sciences. ...
Background:
Italy was the first European country to be involved with the COVID-19 pandemic. As a result, many healthcare professionals were deployed and suddenly faced end-of-life care management and its challenges.
Aims:
To understand the experiences of palliative care professionals deployed in supporting emergency and critical care staff during the COVID-19 first and second pandemic waves.
Research design:
A qualitative descriptive design was adopted, and in-depth interviews were used to investigate and analyse participants' perceptions and points of view.
Participants and research context:
Twenty-four healthcare professionals (physicians, nurses, psychologists, physiotherapists, and spiritual support) from the most affected areas of Italy were recruited via the Italian society of palliative care and researchers' network.
Ethical considerations:
The University Institutional Board granted ethical approval. Participants gave written informed consent and agreed to be video-recorded.
Findings:
The overarching theme highlighted participants' experience supporting health professionals to negotiate ethical complexity in end-of-life care. Crucial topics that emerged within themes were: training emergency department professionals on ethical dimensions of palliative and end-of-life care, preserving dying patients' dignity and developing ethical competence in managing end-of-life care.
Conclusions:
Our study showed palliative care teams' challenges in supporting health professionals' ethical awareness in emergencies. However, while they highlighted their concerns in dealing with the emergency staff's lack of ethical perspectives, they also reported the positive impact of an ethically-informed palliative care approach. Lastly, this study illuminates how palliative care professionals' clinical and ethical competence might have assisted a cultural change in caring for dying patients during COVID-19 and future emergencies.
... The frequent emergency department (ED) visits of patients with advanced cancer indicated unmet palliative care needs and the low quality of palliative care at the end of life [1]. Generally, patients and families describe these visits as unpleasant experiences [2]. This can be attributed to several factors, including long wait times due to their patients' ranking second to critically ill patients, a lack of adequate symptom palliation, ineffective communication due to the noisy and impersonal environment, and a lack of dedicated space for relatives to wait for examinations or a place to discuss advance care planning during the final stages of life [2,3]. ...
... Generally, patients and families describe these visits as unpleasant experiences [2]. This can be attributed to several factors, including long wait times due to their patients' ranking second to critically ill patients, a lack of adequate symptom palliation, ineffective communication due to the noisy and impersonal environment, and a lack of dedicated space for relatives to wait for examinations or a place to discuss advance care planning during the final stages of life [2,3]. Significant barriers to providing appropriate palliative care in the ED include the absence of longterm relationships between ED physicians and patients; insufficient staff training in symptom management; and essential communication skills, such as discussing the goal of care and advance care planning [4][5][6]. ...
Abstract Purpose Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients. Methods A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16–100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p-value 0.01) were less likely to attend the ED. In contrast, PPS 50–90% (OR 2.02; 95%CI 1.18, 3.47; p-value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p-value 0.01) and PPS 50–90% (OR 2.62; 95%CI 1.44, 4.79; p-value 0.01). Conclusions There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.
... 5 PC, which is usually provided in oncology units, has expanded to the extent that it can be served in other clinics and even in the emergency department (ED) with the increasing need. 6 However, EDs are not suitable for long-term treatment of terminal period patients due to their busy, crowded and tiring environments. 7 The aim of this study was to examine patients who apply to emergency services and need palliative care, and to analyze them in terms of both appropriate patient care and effective use of health institutions. ...
Background This study aimed to analyze patients who apply to emergency services and need palliative care regarding appropriate patient care and effective use of health institutions. Materials and Methods The study was conducted prospectively on patients who applied to the emergency services of Bursa Uludag University Health Application and Research Center, Health Sciences University Bursa Yüksek Ihtisas Training and Research Hospital and Bursa City Hospital between 15.08.2021 and 15.02.2022 and needed palliative care. Results A total of 261 patients, 143 male (54.8%) and 118 female (45.2%), were included in the study. It was determined that 50 (19.1%) of these patients had previously received palliative care services. It was determined that the patients included in the study applied to the emergency services 7.52±6.77 times in the last year. The three most common diseases diagnosed in patients admitted to the emergency department were pneumonia (24.5%), urinary system infection (7.7%), and cerebrovascular disease (5.4%). Of the patients, 39.84% were referred/hospitalized, 25.28% were referred/hospitalized to intensive care units, 2.68% refused treatment, 2.68% died, and 29.5% have been discharged. Conclusion As a result, it is understood that most of the patients in need of palliative care do not receive this service, and patients who can be treated in palliative care units are treated in clinics and intensive care units.
... The importance of preserving self-identity gives credence to healthcare professionals' warnings against a "tick-box approach" [5]. The findings support shared decision-making and personcentred care during ACP [8,50,51]. Uncertainty and frustration with ACP jargon by participants sends a powerful message to clinicians to use clear, accessible language and check understanding during discussions. Co-designing approaches to facilitate ACP discussions with older adults may prove beneficial in this regard. ...
Background
There is increasing evidence of the need to consider advance care planning (ACP) for older adults who have been recently admitted to hospital as an emergency. However, there is a gap in knowledge regarding how to facilitate ACP following acute illness in later life.
Aim/Objectives
To explore the perceived impact of ACP on the lives of older persons aged 70+ who have been acutely admitted to hospital.
Method
Semi-structured qualitative interviews were conducted with older adults aged 70+ who were admitted to hospital as an emergency. Thematic analysis was enhanced by dual coding and exploration of divergent views within an interdisciplinary team.
Results
Twenty participants were interviewed. Thematic analysis generated the following themes: (1) Bespoke planning to holistically support a sense of self, (2) ACP as a socio-cultural phenomenon advocating for older persons rights, (3) The role of personal relationships, (4) Navigating unfamiliar territory and (5) Harnessing resources.
Conclusion
These findings indicate that maintaining a sense of personal identity and protecting individuals’ wishes and rights during ACP is important to older adults who have been acutely unwell. Following emergency hospitalization, older persons believe that ACP must be supported by a network of relationships and resources, improving the likelihood of adequate preparation to navigate the uncertainties of future care in later life. Therefore, emergency hospitalization in later life, and the uncertainty that may follow, may provide a catalyst for patients, carers and healthcare professionals to leverage existing or create new relationships and target resources to enable ACP, in order to uphold older persons’ identity, rights and wishes following acute illness.
... The conditions that determine clinical urgency for critically ill patients in general are not the same as those that define urgency of care for PC patients, where relief of physical suffering is perhaps the aspect of priority and not necessarily resuscitation strategies and invasive measures. 7 A previously developed tool has been created to identify PC needs, but not to triage priorities for care of palliative patients in EDs. 8 ...
Objective
We aimed to develop and validate a new emergency triage tool for use on patients with cancer undergoing palliative care (PC).
Methods
In phase I, the new tool was developed after literature review and expert committee meetings. A prospective longitudinal study in phase II assessed the interobserver reliability of the tool. In phase III, a retrospective study of administrative data, the feasibility of routine use of the new tool and the associations with hospitalisation and survival times were evaluated.
Results
The palliative care triage system (PCTS) was composed of check-list items and four colour-coded categories for maximum response time. In phase II, the PCTS was independently evaluated by two nurses for 102 attendances in the emergency department of the PC unit. An absolute agreement of 87.3% and a weighted kappa of 0.81 were observed. In phase III, all 493 attendances had the PCTS assessment registered in the medical records. The PCTS categories were associated with hospital admission (p<0.001) and survival times (p<0.001).
Conclusion
PCTS is a feasible tool to be used in routine ED triage of patients with advanced cancer undergoing PC. It is a valid instrument for predicting hospital admission rates and survival with high interobserver concordance rates.
... Accordingly, it highlighted the need to address advance care planning (ACP) and issues related to LST in the EOL care context. However, there is a lack of evidence on the state of medical care provided under constraints such as EDs, especially in Korea; nor are there major discussions on EOL care strategies in the ED [32][33][34][35]. ...
Background
High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.
Methods
We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.
Results
Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness ( p = 0.011) and the lack of an advance statement ( p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) ( p = 0.002) and those who completed life-sustaining treatment legal forms ( p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).
Conclusions
Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.
... 22 While many studies have investigated promoting GOC discussions in the ED, the characteristics and demands of the ED make it a challenging setting to engage patients and their families in delicate conversations regarding GOC. [23][24][25] Given that the current study could not confirm directly with the patients as to their GOC status, it is possible that more patients had GOC that were just not consistently documented in the patients' medical charts. 26 At the time of the study, no electronic medical record (EMR) systems were implemented at either of the study sites and there was no formal method for ED physicians or nurses to document GOC in the patient's paper charts. ...
Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March-August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.
