Palliative Care Emergency Research Articles

Simulation as possible training for palliative emergencies: prospective initial data analysis of participants from two simulation training sessions

Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. This article presents the preparation of recommendations in the training and development of palliative care emergency situations. A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Palliative care and prehospital emergency medicine: analysis of a case series.

Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients—or more often their families or entourages—are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward.We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland.The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting end-of-life and palliative care situations that may be encountered by prehospital emergency services.The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients’ family members.

Can early introduction of specialized palliative care limit intensive care, emergency and hospital admissions in patients with severe and very severe COPD? a randomized study.

BackgroundCOPD is a progressive lung disorder with rates of mortality between 36–50%, within 2 years after admission for an acute exacerbation. While treatment with inhaled bronchodilators and steroids may partially relieve symptoms and oxygen therapy may prolong life, for many patients the course of the disease is one of inexorable decline. Very few palliative care intervention studies are available for this population. This trial seeks to determine the effectiveness of the introduction of specialized palliative care on hospital, intensive care unit and emergency admissions of patients with severe and very severe COPD.Methods/DesignThe study is a three year single centre, randomized controlled trial using a 2 arms parallel groups design conducted in a tertiary center (University Hospitals; Geneva). For the intervention group, an early palliative care consultation is added to standard care; the control group benefits from standard care only. Patients with COPD defined according to GOLD criteria with a stage III or IV disease and/or long term treatment with domiciliary oxygen and/or home mechanical ventilation and/or one or more hospital admissions in the previous year for an acute exacerbation are eligible to participate. Allocation concealment is achieved using randomisation by sealed envelopes. Our sample size of 90 patients/group gives the study a 80% power to detect a 20% decrease in intensive care unit and emergency admissions – the primary endpoint. All data regarding participants will be analysed by a researcher blinded to treatment allocation, according to the "Intention to treat" principle.DiscussionGiven the trends toward aggressive and costly care near end-of-life among patients with COPD, a timely introduction of palliative care may limit unnecessary and burdensome personal and societal costs, and invasive approaches. The results of this study may provide directions for future palliative care interventions in this particular population.Trial registrationThis trial has been registered at clinicaltrials.gov under NCT02223780

Primary care management of palliative care emergencies

There are relatively few true emergencies in palliative care, but an ability to deal with those that do occur is crucial. Managing major haemorrhage, superior vena cava obstruction or terminal agitation may be a daunting prospect for GPs, and equipping ourselves with the necessary skill set in advance of needing to apply it is vital. In situations where immediate action is required, the goal is usually to prevent a sudden or catastrophic worsening in the patient’s quality of life or symptoms, or to manage a potentially unpleasant mode of death.

Scope of management of emergencies in palliative care

Abstract Patients receiving palliative care may deteriorate suddenly due to their illness or another acute medical or surgical problem. Management options depend on life expectancy, level of intervention needed, and an assessment of risks, benefits, side effects and likely outcome. Symptom control and supportive care may be the most appropriate management if the patient is dying. Treatment options are to be discussed with the patient and family; if possible, discussion and documentation of the patient’s wishes should be made in advance including those about resuscitation, hospital admission and transfer to an intensive care unit.

Understanding and Accessing Palliative Care Services for Patients with Progressive Illness

As our country’s population ages, there are more patients with advanced chronic illness and increasingly complex care needs. Our rapidly changing healthcare environment now recognizes the importance of improving care quality to achieve better health outcomes while lowering cost and improving patient satisfaction. This focus solidified the emergence of Palliative Care as an essential specialty to provide the comprehensive care that these patients with advanced chronic illness require. Palliative Care assists patients and families with difficult decision-making, addresses pain and other distressing symptoms, helps prolong life, controls costs, and most importantly, improves patient and family satisfaction. To maximize the benefits of palliative care, practicing Family Physicians need to develop primary palliative care knowledge and skills while recognizing when specialty level palliative care is required. Prognostication is an essential skill as it allows patients and families to establish realistic goals of care that will guide medical decision making throughout the disease trajectory. In all settings, primary and specialty level palliative care is best delivered by an interdisciplinary team with the Family Physician as an essential team member.

SUPPORTING GENERAL PRACTITIONERS TO PROVIDE OUT-OF-HOURS PALLIATIVE CARE

IntroductionOffering choice about place of care to patients is fundamentally influenced by out-of-hours service provision. Concerns have been raised about continuity, availability of information and access to support services. General...

OUT-OF-HOURS PALLIATIVE CARE: WHAT ARE THE EDUCATIONAL NEEDS AND PREFERENCES OF GENERAL PRACTITIONERS?

BackgroundGeneral practitioners (GPs) provide most out-of-hours medical care, but overall see few palliative patients. Keeping their knowledge and skills up-to-date is challenging. UK national policy has highlighted the importance of...

Breaking down the silos: Collaboration delivering an efficient and effective response to palliative care emergencies

ObjectivesThe objective of this article is to explore the introduction of a rapid response team as outlined in the South Australian Palliative Care Services Plan 2009–2016. The Plan identifies this service as being provided by nurse practitioners. This workforce is not yet fully developed so a partnership model utilizing the extended care paramedic has been explored for the provision of out-of-hours emergency care to palliative patients.MethodsA working group was established under the auspices of the Palliative Care Clinical Network to progress the partnership model of care. Key stakeholders from SA Ambulance, the Royal District Nursing Society, Flinders University, and Specialist Palliative Care Services (SPCS) made up the steering committee. Satisfaction telephone surveys were conducted following the trial phase to assess the community acceptance of this model.ResultsData were collected from across the metropolitan area of Adelaide. There were 40 paramedic visits during the 118 days of the trial, which equates to 10 days per month. About 78.5% of the patients requiring this service were registered with a SPCS. Satisfaction from patients, caregivers, and the extended care paramedics was high.ConclusionsThis partnership model has enabled an emergency after-hours service to be provided between the SPCS and the ambulance service. This unlikely alliance has been very well received by patients and family members wishing to remain at home. Early data reveals that 90% of unnecessary and unwanted admissions to hospitals have been avoided in the palliative care population.

Facing Persistent Challenges in Pediatric Decision-Making: New Hastings Center Guidelines

Approximately 50 000 deaths occur among pediatric patients (neonates, infants, children, and adolescents) in the United States each year. These deaths are a small fraction of the 2.5 million annual deaths in the United States, but they have an immense impact on the families and clinicians who care for these patients. Persistent challenges in providing care to seriously ill pediatric patients continue, despite evidence-based approaches to treatment decision-making, the emergence of pediatric palliative care as an interdisciplinary subspecialty, and the growing number of children’s hospitals. Clinicians report significant lack of knowledge about ethical and legal issues that have been addressed and seemingly resolved by consensus groups and major pediatric organizations.1 They voice concerns of conscience about providing end-of-life care. Most agree that we sometimes save the life of a child without sufficient regard for the profound consequences of our interventions on a child’s subsequent quality of life. These knowledge gaps and professional concerns may lead to tension within teams and confusion about how to provide good care. This article is written to introduce pediatric clinicians to several relevant aspects of a set of ethics guidelines recently published by the Hastings Center, an independent, nonprofit bioethics research institution that since 1969 has been a major source of interdisciplinary research on ethical challenges in clinical medicine.2 The new guidelines update the first edition (1987) and include a major new section on pediatric decision-making, with other material relevant to the care of children, building on research and practice insights from pediatric subspecialties, pediatric palliative care, and interdisciplinary bioethics. We will address key challenges and their implications for all professionals who aim to understand, respect, and provide good care to children and families, throughout treatment and at the end of life. Serving as a surrogate decision-maker for any patient can be psychologically difficult. … Address correspondence to Nancy Berlinger, PhD, Research Department, The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524. E-mail: berlingern{at}thehastingscenter.org

High-Dose Neuroleptics and Neuroleptic Rotation for Agitated Delirium Near the End of Life

Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses. This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. Each patient experienced considerable sedation, though this was an acceptable side effect for the family. Each patient was transferred from the acute care hospital to a location of family preference. There they died within a week of transfer. Agitated delirium is a palliative care emergency. High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium. This remedy can provide the patient with a peaceful dying in a place of their choosing.

Palliative Sedation Versus Euthanasia: An Ethical Assessment

The aim of this article was to review the ethical debate concerning palliative sedation. Although recent guidelines articulate the differences between palliative sedation and euthanasia, the ethical controversies remain. The dominant view is that euthanasia and palliative sedation are morally distinct practices. However, ambiguous moral experiences and considerable practice variation call this view into question. When heterogeneous sedative practices are all labeled as palliative sedation, there is the risk that palliative sedation is expanded to include practices that are actually intended to bring about the patients' death. This troublesome expansion is fostered by an expansive use of the concept of intention such that this decisive ethical concept is no longer restricted to signify the aim in guiding the action. In this article, it is argued that intention should be used in a restricted way. The significance of intention is related to other ethical parameters to demarcate the practice of palliative sedation: terminality, refractory symptoms, proportionality, and separation from other end-of-life decisions. These additional parameters, although not without ethical and practical problems, together formulate a framework to ethically distinguish a more narrowly defined practice of palliative sedation from practices that are tantamount to euthanasia. Finally, the article raises the question as to what impact palliative sedation might have on the practice of palliative care itself. The increasing interest in palliative sedation may reemphasize characteristics of health care that initially encouraged the emergence of palliative care in the first place: the focus on therapy rather than care, the physical dimension rather than the whole person, the individual rather than the community, and the primacy of intervention rather than receptiveness and presence.

MORECARE CAPACITY: MENTAL CAPACITY AND PROCESSES OF CONSENT FOR RESEARCH ON END-OF-LIFE CARE

IntroductionA major barrier to improving end-of-life care (EoLC) is the inclusion of those near to death in research studies. The Mental Capacity Act 2005 clarified concepts on involving adults lacking...

International recommendations for outpatient palliative care and prehospital palliative emergencies – a prospective questionnaire-based investigation

BackgroundTo determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts.MethodsOne hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical .ResultsThe total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of “Palliative Care Teams” (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and “Do not attempt resuscitation” orders and (4) emergency medical training (physicians and paramedics).ConclusionsThis study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

Opioid use and effectiveness of its prescription at discharge in an acute pain relief and palliative care unit

The aim of this study was to present how opioids are used in an acute pain relief and palliative care unit (APRPCU), where many patients with difficult pain conditions are admitted from GPs, home palliative care programs, oncology departments, other hospitals or emergency units, and other regional places. From a consecutive sample of cancer patients admitted to an APRPCU for a period of 6 months, patients who had been administered opioids were included in this survey. Basic information was collected as well as opioid therapy prescribed at admission and, subsequently, during admission and at time of discharge. Patients were discharged once stabilization of pain and symptoms were obtained and the treatment was considered to be optimized. One week after being discharged, patients or relatives were contacted by phone to gather information about the availability of opioids at dosages prescribed at time of discharge. One hundred eighty six of 231 patients were specifically admitted for uncontrolled pain, with a mean pain intensity of 6.8 (SD 2.5). The mean dose of oral morphine equivalents in patients receiving opioids before admission was 45 mg/day (range 10-500 mg). One hundred seventy five patients (75.7 %) were prescribed around the clock opioids at admission. About one third of patients changed treatment (opioid or route). Forty two of 175 (24 %), 27/58 (46.5 %), 10/22 (45.4 %), and 2/4 (50 %) patients were receiving more than 200 mg of oral morphine equivalents, as maximum dose of the first, second, third, and fourth opioid prescriptions, respectively. The pattern of opioids changed, with the highest doses administered with subsequent line options. The mean final dose of opioids, expressed as oral morphine equivalents, for all patients was 318 mg/day (SD 798), that is more than six times the doses of pre-admission opioid doses. One hundred eighty six patients (80.5 %) were prescribed a breakthrough cancer pain (BTcP) medication at admission. Sixty five patients changed their BTcP prescription, and further 27 patients changed again. Finally, eight patients were prescribed a fourth BTcP medication. Of 46 patients available for interview, the majority of them (n = 39, 84 %) did not have problems with their GPs, who facilitated prescription and availability of opioids at the dosages prescribed at discharge. For patients with severe distress, APRPCUs may guarantee a high-level support to optimize pain and symptom intensities providing intensive approach and resolving highly distressing situations in a short time by optimizing the use of opioids.

Introduction and evaluation of an upskilling programme for GPs

In response to the educational needs of local GPs, as highlighted in their professional development plans and experience from day to day practice in palliative care, we set up a...

Management of hypercalcaemia at hospice setting

ObjectiveHypercalcaemia of malignancy is a palliative care emergency that needs early intervention. Bisphosphonate therapy improves the morbidity of acute hypercalcaemia, reduce bone pain and pathological fractures. North of England Cancer...

Palliative care and prehospital emergency medicine – apparently conflicting approaches?

Palliative care and prehospital emergency medicine – apparently conflicting approaches?

Caring for a Head-Injured Patient with Terminal Agitation in A&E

The predominant culture within accident and emergency (A&E) departments is to save lives. Consequently, end-of-life care (EoLC) may be given low priority in the A&E setting. As death approaches, patients may become restless, agitated or delirious. All potential causes of agitation at the end of life should be considered, assessed and treated if possible. The source of agitation can be difficult to ascertain when a patient is unconscious. Terminal agitation should always be considered a palliative care emergency. This article is based on a case scenario detailing the EoLC provided to a 70-year-old man following trauma-induced cerebral haemorrhage within an A&E department. The assessment and management of the dying process is discussed, in particular, the management of terminal agitation in a patient with severe head injury. The aim of this work is to enable A&E nurses to consider the means by which EoLC can be provided to dying trauma patients in an environment where time constraints and curative treatment models often prevent such care provision. Anonymity of the patient is maintained by the use of a pseudonym ([Nursing and Midwifery Council, 2008][1]). Conflicts of interest: none [1]: #ref-48

Emergencies in palliative care

Emergencies in palliative care