Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors

Palliative care education: a nationwide qualitative study of emergency medicine residency program directors in the United Arab Emirates

BACKGROUND

Emergency medicine (EM) physicians routinely care for patients with serious life-limiting illnesses. Educating EM residents to have general skills and competencies in palliative medicine is a global priority. The purpose of this study was to describe the current status of palliative and end-of-life education in EM residency programs in the United Arab Emirates (UAE) and to identify barriers and opportunities to inculcating palliative care (PC) instruction into EM training in a non-Western setting.

METHODS

Using the American College of Emergency Medicine's milestones for Hospice and Palliative Medicine for Emergency Medicine as a question guide, semi-structured interviews were conducted with program directors of all 7 EM residency programs in the UAE from January through July 2023. Qualitative content analysis was conducted to identify recurring themes.

RESULTS

All program directors agreed that PC knowledge and skills are essential components of training for EM residents but have had variable success in implementing a structured PC curriculum. Six themes emerged, namely the educational curriculum, PC policies and practices, comprehensive PC services, cultural and religious barriers to PC, EM scope of practice, and supporting residents after patient death.

CONCLUSION

UAE national EM residency curriculum development is evolving with an emphasis on developing a structured PC curriculum. As EM residencies implement policies and programs to improve care for patients and families dealing with serious illness, future studies are needed to assess the impact of these initiatives on patient quality of life and physician well-being.

Emergency Palliative Care: Patient With Cancer Diagnosis and Escalating Symptom Burden

In this segment of the emergency department (ED) palliative care (PC) case series, we present a patient with advanced cancer not yet followed by PC or on hospice, who presents to the ED overnight with worsening nausea, vomiting, and acute on chronic abdominal pain. The ED team works to stabilize and treat the patient, reaches out to his oncologist, and seeks remote support and guidance from the on-call PC clinician. After a rapid "just-in-time" training, the ED clinician is able to have a focused goals-of-care conversation with the patient and his family and make person-centered recommendations. The patient is briefly admitted to the intensive care unit for ongoing medical optimization and symptom management, and then subsequently discharged home on hospice in alignment with his elucidated goals.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study

BACKGROUND

During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different.

METHODS

We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews.

RESULTS

Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies.

CONCLUSIONS

Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Teaching Palliative Care to Emergency Medicine Residents Using Gamified Deliberate Practice-Based Simulation: Palliative Gaming Simulation Study

BACKGROUND

Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care.

OBJECTIVE

We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills.

METHODS

This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool-Modified survey to evaluate perceived effectiveness in teaching end-of-life management.

RESULTS

Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool-Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient's condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context.

CONCLUSIONS

This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management.

Primary Palliative Care Education for Graduate Medical Trainees: Impacts and Needs

As demand for palliative care (PC) services rise, there are insufficient numbers of PC specialists to provide PC for the US population. "Primary palliative care" refers to PC services that are administered by non-specialist PC providers. Educating trainees in graduate medical education (GME) programs is 1 strategy for expanding primary palliative care, though questions remain regarding the impact of PC education for GME trainees and where additional education is needed. This study is a multicenter, cross-sectional, web-based survey study of GME trainees assessing the needs for and impacts of primary palliative care education. The survey assessed the implementation of and participants' confidence with fundamental PC skills. The survey also asked about prior exposure to PC education and for participants' beliefs regarding areas that would be particularly helpful for future education. 170 residents and fellows from diverse training backgrounds participated in the survey out of 851 potential participants (response rate 19.98%). Exposure to PC education was associated with higher confidence and increased frequency of implementation of fundamental PC skills. Of the forms of education that were assessed, clinical/experiential education was associated most often with higher confidence and higher frequency of use of PC skills. Discussing goals of care, pain management for seriously ill patients, and communicating difficult information were those skills most frequently identified as important for additional training. This study demonstrates that by improving existing PC education or increasing access to PC education for GME trainees, it may be possible to improve primary palliative care.

Knowledge and Attitudes Toward Hospice and Palliative Care: Instrument Validation Among Emergency Providers

Background: Emergency providers can engage in goals of care discussions and hospice and palliative care referrals. Little is known about their knowledge and attitudes, which may influence these care practices. Objective: This study aims to re-validate the knowledge and attitude towards hospice and palliative care (KAHP) scale and assess the scale's latent constructs among emergency providers. Methods: The scale consists of ten items measured on a five-point Likert scale. Five of the ten items were reverse scored. Content validation was performed by ten experts in Hospice and Palliative Medicine and Emergency Medicine. Baseline surveys of emergency physicians, advance practice providers, and nurses conducted in the context of a pragmatic, randomized control trial were used for the item analysis and the exploratory and confirmatory factor analyses. Results: The KAHP scale is a ten-item scale scored from 10 to 50. Based on the synthesis of content validation results and the item analysis, all ten items were retained. The item and scale Content Validity Index were each .91. The reliability of the scale was .64 and the exploratory factor analysis identified three underlying constructs defined as self-rated knowledge, support for hospice and palliative care practice, and views on provider-patient communication. The presence of good model fit indices supported the structural integrity of the constructs. Conclusion: We present a validated instrument that is suitable for assessing knowledge and attitude variations toward interventions designed to improve hospice and palliative care practice among emergency providers.

Primary Palliative Care in the Emergency Department and Acute Care Setting

Amidst a global COVID pandemic, the palliative care community and healthcare systems around the country continue to explore opportunities to improve early patient and family access to end-of-life care resources. They need not look any further than the Emergency Departments (ED) located on their campuses and around their communities for this chance. As advances in medical therapies continue to extend disease specific life expectancies and as the American population continues to age, we will continue to see older adults with chronic medical illnesses visiting the ED in their final stages of life (Smith et al. in Health Aff (Millwood) 31(6):1277-1285, 2012; Albert et al. in NCHS Data Brief 130:1-8, 2013). If the ED is to continue to be the primary portal of hospital entry for patients requiring emergent care for acute and chronic terminal illnesses, then it stands to reason that it should also be equally prepared to provide the earliest access to palliative care and advance care planning resources for patients and families who may want and benefit from these services. This chapter will explore the unique horizon of opportunities that exist for emergency medicine and the palliative care specialty to fulfill this obligation. Discussion will be centered around core principles in screening, assessment, and management of palliative care needs in the ED, importance of goals of care conversations, and the coordination of early palliative care and hospice consults that can facilitate safe transitions of care.

Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention

Background

Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework.

Methods

Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM.

Results

The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use.

Conclusions

An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.

Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID

Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.

Assessing the Effect of a Hospice and Palliative Medicine Curriculum on Emergency Medicine Residents' Knowledge

Background: In the average Emergency Medicine (EM) residency program there is little formal Hospice and Palliative Medicine (HPM) training, despite these skills used frequency in the Emergency Department (ED) setting, from symptomatic management to end of life communications. Objective: This research project aims to determine if a Free Open Access Medical Education based HPM curriculum will improve knowledge and comfort level of end-of-life care in EM residents within the ED. The curriculum consisted of an in-person lecture series along with self-directed learning through online modules covering a variety of foundational topics. Methods: A 10-point Likert-scale pre- and post-intervention self-survey, assessing HPM comfort level and foundation/knowledge base and skills, was administered to the residents. Results: 16/18 residents (89%) responded to the pre-intervention survey and 13/18 residents (72%) answered the post-intervention survey. There was a statistically significant increase of the residents' understanding of the difference between hospice and palliative care (pre-intervention mean of 4.44, post-intervention mean of 7.69, P = .004), as well as their perspective of how often they consult those services for patients they see in the ED (pre-intervention mean of 2.19, post-intervention mean of 3.92, P = .02) and their overall understanding of the foundations of this field (pre-intervention mean of 4.19, post-intervention mean of 7.23, P = .0002). Conclusion: The curriculum increased the EM residents' understanding of the foundations of the HPM field, their fundamental knowledge of the differences between the 2 disciplines, and the frequency of how often they consult these specialties in the ED.

Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study

BACKGROUND

Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice.

METHODS

Setting: Academic ED with 82,000 annual visits.

POPULATION

ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition.

RESULTS

Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27).

CONCLUSION

Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.

Registration Attendants Show Poor Readiness to Handle Advanced Care Planning Discussions

Background: Emergency departments (ED) and other medical points of care are required to provide patients with advance directive (AD) information. Although many hospitals provide AD information in EDs, the comfort and preparation of the ED staff with this responsibility is unclear.

Objective: To determine the attitudes, comfort levels, and prior training of ED staff with AD.

Methods: The ED social workers, nurses, registration attendants, residents, and attending physicians at two academic hospitals completed a survey about their attitudes around, preparedness for, and experiences with advance care planning (ACP) discussions in the ED.

Results: We received responses from 220 ED staff. Preparedness to discuss ACP with patients varied by profession. Eighty percent of social workers (n = 4/5) and 52% (n = 16/31) of attending physicians reported preparedness to handle ACP discussions. Registration attendants were the least prepared, and only 4% (n = 1/24) reported preparedness to discuss ACP. Attempts at ACP discussions with patients also differed by profession, with attending physicians being the most likely (77%, n = 24/31), whereas registration attendants were the least likely (8%, n = 2/24). Fifty-nine percent of surveyed staff (n = 130/220) believed that ACP was a component of emergency care, although only 13% (n = 29/220) had received training.

Conclusion: The ED staff are in favor of ACP in the ED. Preparedness for, and attempts of ACP discussions with patients in the ED vary by profession. Attending physicians and social workers tend to be the most prepared, and they report the most frequent attempts at discussions with patients. Despite the fact that registration attendants are frequently tasked with asking about patient ADs, they show little confidence in asking about and discussing such matters. Our research indicates that registration attendants feel unprepared to guide discussions of ADs and should not do so without additional training.

Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting

Background

Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work.

Design

A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these.

Results

A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary.

Limitations

Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis.

Conclusions

Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.

Early palliative intervention in septic patients reduces healthcare utilization

INTRODUCTION

While the role of palliative care in the emergency department is recognized, barriers against the effective integration of palliative interventions and emergency care remain. We examined the association between goals-of-care and palliative care consultations and healthcare utilization outcomes in older adult patients who presented to the emergency department (ED) with sepsis.

METHODS

We performed a retrospective review of 197 patients aged 65 years and older who presented to the ED with sepsis or septic shock. Healthcare utilization outcomes were compared between patients divided into 3 groups: no palliative care consultation, palliative care consultation within 4 days of admission (i.e., early consultation), and palliative care consultation after 4 days of admission (i.e., late consultation).

RESULTS

51% of patients did not receive any palliative consultation, 39% of patients underwent an early palliative care consultation (within 4 days), and 10% of patients underwent a late palliative care consultation (after 4 days). Patients who received late palliative care consultation had a significantly increased number of procedures, total length of stay, ICU length of stay, and cost (p < .01, p < .001, p < .05, p < .001; respectively). Regarding early palliative care consultation, there were no statistically significant associations between this intervention and our outcomes of interest; however, we noted a trend towards decreased total length of stay and decreased healthcare cost.

CONCLUSION

In patients aged 65 years and older who presented to the ED with sepsis, early palliative consultations were associated with reduced healthcare utilization as compared to late palliative consultations.

United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department

The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.

Increasing Awareness of Palliative Medicine With the Emergency Department: A Quality Improvement Project

Palliative medicine can be essential in helping to align patients' goals of care with their treatment team. Referrals for palliative medicine are more advantageous when initiated in the emergency department as this is the first point of contact for seriously ill patients being admitted to the hospital. This paper highlights a quality improvement project initiated to address knowledge gaps in palliative medicine with emergency department (ED) staff and to increase referrals for palliative medicine from the ED. The palliative medicine staff held an in-service training with the ED staff which focused on defining palliative medicine and the importance of early consults when the patient presents in the ED. Palliative medicine staff also highlighted the differences between palliative medicine and hospice care, when and how to initiate a consult for palliative medicine, as well as how to contact the palliative medicine division. The results showed that after this educational intervention the number of palliative medicine consults increased three-fold. Before the educational intervention, monthly averages for palliative medicine were 6 and after rose to 18.9 per month.

Emergency Department Admission Triggers for Palliative Consultation May Decrease Length of Stay and Costs

Background: Emergency department (ED) initiated palliative consultation impacts downstream care utilization. Various admission consult triggers have been proposed without clear best practice or outcomes. Objective: This 18-month single-center study evaluated the clinical, operational, and financial impact of simplified admission triggers for ED-initiated palliative consults as compared to downstream Floor and intensive care unit (ICU) palliative consults initiated per usual practice. Methods: We distilled ED admission triggers into three criteria to ensure bedside actionability and sustainability: (1) end-stage illness, (2) functional limitation, and (3) clinician would not be surprised if the patient died this hospitalization. Eligible patients met all criteria, and received consultation within 24 hours of admission. We compared ED-initiated consults against Floor and ICU consults from March 1, 2018, to September 30, 2019, with matched cohort analysis to evaluate financial outcomes. Results: While overall palliative consult volume remained intentionally steady, the proportion of ED-initiated consults significantly increased (7% vs. 19%, p < 0.001). ED consistently comprised 15-25% of all monthly palliative consults. Compared with Floor, ED had similar ED length of stay (LOS) and inpatient mortality. Among live discharges, ED were more likely to be referred to hospice than Floor (59% vs. 47%, p = 0.24) or ICU (59% vs. 34%, p = 0.02). In a matched cohort analysis, ED demonstrated median cost avoidance of $9,082 per patient versus Floor ($5,578 vs. $14,660, p < 0.001) and $15,138 per patient versus ICU ($5,578 vs. $20,716, p < 0.001). ED had significantly shorter median LOS before consult than Floor (0 vs. 3 days, p < 0.001) or ICU (0 vs. 3 days, p < 0.001), which did not differ between live discharges or inpatient deaths. Overall hospital LOS was disproportionately shorter for ED, with a net difference-in-differences of 1-3.5 days compared to Floor and ICU. Conclusions: Simple ED admission triggers to expedite palliative engagement are associated with a 50-75% reduction in both hospital LOS and costs when compared against usual palliative consultation practice. ED initiation reduces both lead time before consultation and subsequent downstream hospitalization length.

Past, present, and future of palliative care in emergency medicine in the USA

The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill‐equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM–palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high‐quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.

Barriers and Facilitators to Discussing Goals of Care among Nephrology Trainees: A Qualitative Analysis and Novel Educational Intervention

Background: Goals of care (GOC) conversations are critical to advance care planning but occur infrequently in nephrology. National workshops have improved trainee comfort with initiating GOC conversations but lack interface with palliative subspecialists and can incur travel-related costs. We developed an educational intervention focused on GOC conversations for nephrology trainees that incorporated into routine schedules and offered feedback from palliative subspecialists. Objective: To explore barriers and facilitators to discussing GOC and uncover perceptions of GOC-related behavior change post-intervention. Design: Qualitative study. Setting/Subjects: Sixteen nephrology trainees at an academic medical center. Measurements: Analyses of semistructured interviews occurred in phases: (1) isolation of quotes; (2) development of a coding system; and (3) creation of a framework of interrelationships between quotes using an inductive/deductive approach. Results: We captured the following themes: (1) prior knowledge (ability to define GOC, knowledge of communication frameworks and prognostic data, exposure to outpatient GOC conversations; (2) attitudes related to GOC conversations (responsibility, comfort, therapeutic alliance, patient preparedness, partnership with care teams); and (3) potential change in behaviors (increased likelihood to initiate GOC conversations early, more accurate identification of patients appropriate for a GOC conversation). Conclusions: Prior knowledge of, exposure to, and attitudes toward advance care planning were key determinants of a nephrology trainees' ability to initiate timely GOC conversations. After our intervention, trainees reported increased comfort with and likelihood to initiate GOC conversations and an improved ability to identify appropriate candidates. Our intervention may be a novel, feasible way to coach nephrologists to initiate timely GOC conversations.

Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER)

Background

The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations.

Methods

A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback.

Results

The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality.

Conclusions

CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care.

Trial registration

ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844–01.

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases

Introduction

The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment.

Methods

Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis.

Results

We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver's emotions, coping and understanding of patient's illness, patient's wishes, coping and understanding of patient's illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians' knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested.

Conclusion

Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

Would You Be Surprised if This Patient Died in the Next 12 Months? Using the Surprise Question to Increase Palliative Care Consults From the Emergency Department

BACKGROUND

There is a growing movement to increase palliative care consults from the emergency department (ED) to reduce healthcare costs and improve quality of life. The surprise question is a screening tool that emergency medicine physicians may be able to use towards achieving this goal.

OBJECTIVE

The objectives of this study were to increase awareness of hospice and palliative care medicine (HPM) among emergency medicine (EM) providers and to evaluate whether this heightened awareness increased palliative care consults among participating emergency medicine providers.

METHODS

We conducted an anonymous convenience sample survey and two educational interventions about HPM including the surprise question among emergency medicine resident and attending physicians at a large urban public academic quaternary care center from July to November 2018. A report of palliative care consults ordered between August 1, 2017 and January 1, 2019 was generated from the electronic health records used by the hospital. The number of palliative care consults made before and after the educational intervention was compared.

RESULTS

After the first educational intervention centered on the surprise question, palliative care consults from the ED increased from an average of 2.25 per month (range 0 to 8, SD: 2.38) to 12.67 per month (range 9 to 19, SD: 4.01, p < .001).

CONCLUSION

Educating EM physicians about the surprise question can increase the number of palliative care consults from the ED, thereby potentially improving patient care and decreasing costs by avoiding unwanted healthcare interventions.

Palliative Care in the Pediatric Emergency Department: Findings From a Qualitative Study

STUDY OBJECTIVE

Children with medical complexity represent a fragile population and account for the majority of patients followed in pediatric palliative care. Little is known in regard to the role of the emergency department (ED) in caring for the families of children with medical complexity.

METHODS

Semistructured focus groups were held with health care professionals from pediatric emergency medicine, palliative care, complex care, and intensive care to explore their perspective on pediatric palliative care in the ED. Data were transcribed and analyzed with NVivo software, and thematic analysis and theoretic sampling were performed.

RESULTS

From January to October 2016, 58 participants were interviewed. Difficulties providing pediatric palliative care in the ED are related on the one hand to characteristics specific to the ED, such as its culture and its health care professionals' strong emotional responses when caring for children with medical complexity, and on the other hand to factors extrinsic to the ED; mainly, lack of continuity of care. For critically ill children with unknown goals of care and potential for end of life, professionals in the ED should evaluate the clinical situation, contact known health care teams, remain open to families' preferences, alleviate distressing symptoms, and create a caring environment. Communication between teams is targeted by health care professionals to facilitate and improve patient flow and care.

CONCLUSION

Although perspectives differ in regard to how to provide care for pediatric palliative care patients in the ED, several barriers to providing high-quality emergency pediatric palliative care can be overcome.

Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2016

OBJECTIVES

The objectives were to critically appraise the emergency medicine (EM) medical education literature published in 2016 and review the highest-quality quantitative and qualitative studies.

METHODS

A search of the English language literature in 2016 querying MEDLINE, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified 510 papers related to medical education in EM. Two reviewers independently screened all of the publications using previously established exclusion criteria. The 25 top-scoring quantitative studies based on methodology and all six qualitative studies were scored by all reviewers using selected scoring criteria that have been adapted from previous installments. The top-scoring articles were highlighted and trends in medical education research were described.

RESULTS

Seventy-five manuscripts met inclusion criteria and were scored. Eleven quantitative and one qualitative papers were the highest scoring and are summarized in this article.

CONCLUSION

This annual critical appraisal series highlights the best EM education research articles published in 2016.

Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents

Objective

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.

Methods

A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.

Results

Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).

Conclusions

Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework

OBJECTIVES

Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM.

METHODS

The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine.

RESULTS

The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators.

CONCLUSIONS

Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

Palliative Care Training in Cardiology Fellowship: A National Survey of the Fellows

Objectives:

To address perspectives of cardiology fellows on the current state of palliative education and palliative and hospice resource utilization within their fellowship experiences.

Methods:

We conducted an online national survey of cardiology fellows during the 2015 to 2016 academic year. Survey questions aimed to assess perceived importance of palliative care education, level of palliative care education during fellowship, and the structure of palliative care support at respondent institutions. Responses were collected anonymously. A total of 519 programs, including subspecialty programs, were contacted.

Results:

We received 365 responses, a number that represents roughly 14% of all cardiology fellows nationwide during the 2015 to 2016 academic year. Fellows reported discordance in the quality of education between general cardiology and palliative care principles as it relates to care of the patient approaching the end of life. Fellows infrequently received explicit training nor were observed or mentored in delivering end-of-life discussions. Respondents reported an underutilization of palliative care and hospice resources during fellowship training and also a perception that attending faculty were not routinely addressing goals of care.

Conclusions:

Our survey results highlight a need for enhanced palliative care and end-of-life training experiences for cardiology fellows and also suggest underutilization of hospice and palliative care resources for patients with advanced cardiac diseases. These findings create a platform for future work that might: (1) confirm this training deficit, (2) lead to exploration of educational models that could reconcile this deficit, and (3) potentially help improve palliative care support for patients and families facing advanced heart disease.