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

Abstract

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. The present study aims to identify issues important to emergency, palliative care (PC) and oncology clinical staff in managing people with advanced cancer presenting to EDs. We qualitatively explored views of Australian clinicians working in emergency medicine, PC and oncology, via focus groups at two major hospitals and two community PC services in Melbourne, Victoria, and emergency clinicians from all other Australian states and territories via semi-structured telephone interviews. Purposive sampling for both groups ensured representation of experience, discipline and region of work. The focus groups and interviews were audio-recorded, transcribed and a thematic analysis identified issues important to participants. The overarching theme was EDs being 'caught in the middle' when providing care to patients with advanced cancer in the physical environment (privacy, noise, lack of information and delay and lack of defined pathways), the available resources (access block and overcrowding, time pressures, competition with other emergencies, lack of alternatives) and the roles and expectations of the staff providing care (seniority and comfort with dying, views of dying in the ED, expertise and comfort in caring for those with advanced illness). Despite limitations in the ED environment and resources, clinicians in oncology, PC and emergency medicine support the important role the ED plays in providing the necessary access and expertise for people with advanced cancer.