Abstract
Green E, Ward S, Brierly W: “They shouldn't be coming to the ED, should they?” A descriptive service evaluation of why patients with palliative care needs present to the emergency department. Am J Hospice Palliat Care 2017 [Epub ahead of print]; DOI: https://dx-doi-org.web.bisu.edu.cn/10.1136/bmjspcare-2015-000999
Patients with palliative care needs frequently utilize the emergency department (ED). There is no international agreement on which patients are best cared for in the ED, compared with the primary care setting or direct admission to the hospital. This article presents the quantitative phase of a mixed-methods service evaluation, exploring the reasons why patients with palliative care needs present to the ED. The study was a single-center, observational study, including all patients under the care of a specialist palliative care team who presented to the ED over a 10-week period. Demographic and clinical data were collected from electronic health records. Results demonstrated that a total of 105 patients made 112 presentations to the ED. The two most common presenting complaints were shortness of breath (35%) and pain (28%). Eighty-three percent of presentations required care in the ED according to a priori defined criteria. They either underwent urgent investigation or received immediate interventions that could not be delivered in another setting, were referred by a healthcare professional, or were admitted. The authors conclude that their findings challenge the misconception that patients known to a palliative care team should be cared for outside the ED. The importance and necessity of the ED for patients in their last years of life have been highlighted, specifically in terms of managing acute, unpredictable crises. Future service provision should not be based solely on a patient's presenting complaint. The authors suggest that further qualitative research exploring patient perspective is required to explore the decision-making process that leads patients with palliative care needs to the ED.
Brody BD, Meltzer EC, Feldman D, et al.: Assessing decision-making capacity for Do Not Resuscitate requests in depressed patients: How to apply the “Communication” and “Appreciation” criteria. HEC Forum 2017 [Epub ahead of print]; DOI: 10.1007/s10730-017-9323-6
The Patient Self Determination Act (PSDA) of 1991 brought needed attention to the importance of advance care planning and surrogate decision making. The purpose of this law is to ensure that a patient's preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity (DMC). In general, patients are presumed to have DMC. A patient's DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression, or other psychiatric symptoms are identified or suspected. Physicians and other healthcare professionals working in hospital settings, where medical illness is frequently comorbid with depression, adjustment disorders, demoralization, and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders. This article discusses how to address such an issue.
Jackson-Jordan E, Stafford C, Stratton C, et al.: Evaluation of a chaplain residency program and its partnership with an in-patient palliative care team. J Health Care Chaplain 2017 [Epub ahead of print]; DOI: https://dx-doi-org.web.bisu.edu.cn/10.1080/08854726.2017.1324088
In 2009, a Consensus Conference of experts in the field of spiritual care and palliative care recommended the inclusion of board-certified professional chaplains with at least 1600 hours of clinical pastoral education as members of palliative care teams. This study evaluated a clinical pastoral education residency program's effectiveness in preparing persons to provide spiritual care for those with serious illness and in increasing the palliative care team members' understanding of the chaplain as part of the palliative care team. Results demonstrated that chaplain residents felt the program prepared them to provide care for those with serious illness. It also showed that chaplain residents and palliative care team members view spirituality as an integral part of palliative care and see the chaplain as the team member to lead that effort. The authors suggest that program improvements should include longer palliative care orientation period, more shadowing with palliative care team members, and improved communication between palliative care and the chaplain residents.
Gao M, Slaven M: Best practices in children's bereavement: A qualitative analysis of needs and services. J Pain Manage 2017;10:119–126.
The death of a loved one is a tumultuous, confusing, and emotional time for children. The purpose of the study was to consolidate the knowledge, resources, and recommended practices concerning children's bereavement so as to better understand their need for support and how to meet it. The authors conducted a qualitative analysis of the current and best practices supporting children's bereavement through interviewing experts and examining relevant literature. They used theoretical sampling and purposeful sampling techniques such as maximum variation to generate expert interviews. They also used the constant comparative method until thematic saturation was accomplished. Results demonstrated that themes are divided into two major sections: unique aspects of children's grief and recommended practices. Experts noted that children may experience grief in short spurts and then return to their daily activities, that some children may grieve at each developmental stage and milestone, and that children may try to console their parents at the expense of addressing their own grief. Recommendations include using proper medical terminology and avoiding euphemisms, normalizing grief, peer support with other bereaved children, and therapies in addition to one-on-one counseling such as art therapy and play therapy among others. The authors conclude that there is consistent evidence throughout the literature and agreed upon by experts regarding how children experience grief and what services should be available to them. Expert knowledge and recommendations can be situated in theoretical knowledge on grief, the dual process model of coping and the chronic sorrow model. Further research is recommended to better address the needs of this very vulnerable population.
Prabhakaran S, Cox M, Lytle B, et al.: Early transition to comfort measures only in acute stroke patients. Analysis from the Get With The Guidelines–Stroke registry. Neurol Clin Pract 2017 [Epub ahead of print]; DOI: 10.1212/CPJ.0000000000000358
Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines–Stroke registry. The authors identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order. Results demonstrated that among 963,525 patients from 1675 hospitals, 54,794 (5.6%) had an early CMO order (IS 3.0%; ICH 19.4%; SAH 13.1%). Early CMO use varied widely by hospital (range 0.6%–37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs. no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH and ICH than acute ischemic stroke patients. The authors conclude that early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.
McGinley J, Waldrop DP, Clemency B: Emergency medical services providers' perspective of end-of-life decision making for people with intellectual disabilities. JARID 2017 [Epub ahead of print]; DOI:10.1111/jar.12363
Emergency medical services (EMS) providers are often called to rapidly determine and act upon patients' wishes for end-of-life care. People with intellectual disabilities are living increasingly longer with complex conditions leading to international calls for person-centered advance care planning. Yet, best estimates suggest that very few people with intellectual disabilities document their wishes. This exploratory-descriptive study incorporated mixed methods to analyze data collected consecutively (surveys, n = 239; interviews, n = 48) with EMS providers from five agencies. Data were subjected to a sequential quantitative–qualitative analysis applying a critical discourse analysis framework. Results demonstrated that 62.7% had treated a person with intellectual disability who had medical orders directing end-of-life care. Three themes (provider familiarity, organizational processes, and sociocultural context) offer insights about how medical orders inform EMS providers during calls involving people with intellectual disabilities. The authors conclude that multiple contexts influence how wishes are documented and care provided to people with intellectual disabilities near life's end.