Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation

Comparison of Palliative Knowledge and Self-Efficacy Expectation of German Paramedics Between a Rural and an Urban Structured Emergency Medical Service Area

OBJECTIVE(S)

Differences in the German emergency medical service (EMS) can be seen in the countryside in contrast to the city with regard to travel distances to hospitals and in the access routes of EMS-physicians. In order to investigate the success of establishment of palliative crisis cards associated with training and the rural and urban EMS structures, two urban and two rural EMS areas were compared using the Paramedic Palliative Care Test (PARPACT). Methods: The PARPACT includes test items on palliative knowledge (PK, maximum score: 15 points) and palliative self-efficacy expectations (PSE, maximum score: 18 points), as well as items on palliative attitudes in dealing with palliative care patients. We used a 4-point Likert-type scale. For data analysis, nonparametric tests (χ-test and Mann-Whitney U test) were used in addition to descriptive analysis (frequencies, means, medians, standard deviations, and ranges). Results: In total, 291 out of 750 ambulance or EMS personnel participated in the voluntary survey. Rural ambulance or EMS personnel answered the PK-questions correctly more often on average (mean: 11.19, SD: 1.85) than urban ambulance or EMS personnel (mean: 9.18, SD: 2.39; Mann-Whitney U test: U=5040.000, P=.001). In addition, ambulance or EMS personnel with the highest level of training (3-year-trained paramedics) performed better in PK (mean: 10.38, SD: 2.31) than less intensively training ambulance or EMS personnel (mean: 9.58, SD: 2.43; Mann-Whitney U-test: U=8446.500, P=.004). In terms of PSE, rural ambulance or EMS personnel also achieved higher mean PSE-scores (mean: 12.55, SD: 2.60) than urban ambulance or EMS personnel (mean: 9.77, SD: 3.41; Mann-Whitney U-test: U=5148.500, P=.001). Conclusions: Better training in the EMS is associated with improved PK compared to less qualified nonphysician EMS staff. The establishment of palliative crisis cards and the structures in the city alone do not lead to improved knowledge and PSE.

Emergency medical services and palliative care: a scoping review

OBJECTIVES

The aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present?

DESIGN

A scoping review of literature was performed with an a priori search strategy.

DATA SOURCES

MEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines.

RESULTS

In total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS' palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration.

CONCLUSION

EMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

BACKGROUND

Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions.

METHODS

This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed.

RESULTS

There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing.

CONCLUSION

The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Approaching the End of Their Lives Under Blue Lights and Sirens - Scoping Review

CONTEXT

Emergency medical services (EMS) are frequently responding to calls involving patients in advanced stages of incurable diseases. Despite the competencies and potential of EMS in supporting patients and their families facing symptoms of advanced progressive illnesses, the role of EMS in providing palliative care remains unclear.

OBJECTIVE

The following research question was formulated: What is the role of ambulance EMS, EMS dispatch centres, paramedics and emergency medical physicians in the provision of palliative care to terminally ill patients?

METHODS

Following PRISMA-ScR guidelines, online bibliographic databases CINAHL Complete, MEDLINE Complete (EBSCO), PubMed and MEDLINE (Ovid) were searched from the initial year of database to September 2019. No language restrictions were applied.

RESULTS

31 articles were included in the qualitative synthesis and 3 main roles and one contextual factor were identified: (1) Providing complex care; (2) Adjusting patient's trajectory; (3) Being able to make decisions in a time and information limited environment; (4) Health care professionals are insufficiently supported in palliative care.

CONCLUSION

There are limited data on the incidence of EMS calls to the patients at the end-of-life and no data focusing on the EMS dispatch centres. Both paramedics and emergency physicians are aware of their role in the end-of-life care. EMS personnel are lacking special training and education in the palliative care. Cooperation between palliative care providers, the EMS providers and other out-of-hours services might improve the responsiveness of the health care system to needs and expectations of patients and their families, and possibly improve the overall health care system efficiency.

Hospice and Comfort Care Patient Utilization of Emergency Medical Services

Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.

South African paramedic perspectives on prehospital palliative care

Background

Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice.

Methods

A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings.

Results

Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist.

Conclusion

Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Management of oncology-related emergencies at the emergency department: A long-term undertaking

Background:

The emergency department at the Singapore General Hospital is an emergency department with an annual census of 140,000 and oncology-related attendances of about 4000 (2.8%). These patients are often admitted for further care. Palliative care in the emergency department for these patients is often minimal. The aim of this study was to determine the state of current management of oncology-related emergencies at the Singapore General Hospital’s emergency department, hence identifying specific areas for intervention.

Methods:

We carried out a retrospective data review of all Singapore General Hospital’s emergency department patients who had either cancer-related diagnoses or were admitted to the Medical Oncology Department in October 2018. Simple statistical analysis was then performed using IBM SPSS version 21.

Results:

Of 308 identified patients, there was approximately equal distribution by sex. The women were generally younger than the men (61.33 ± 13.63 years vs 67.36 ± 12.02 years, p = 0.063, confidence interval −8.94 to −3.13). Seventy-two (23.4%) of the patients arrived at emergency department by ambulance. The mean emergency department length of stay was 4.25 h. About half of the patients had either lung, colorectal, or breast as their primary site of cancer. There was no correlation between clinical severity according to the National Early Warning Scores and triage complaint-type or emergency clinical diagnosis. More than 90% were admitted, with about 32.6% dying during their inpatient stay. High National Early Warning Scores were significantly associated with mortality.

Conclusion:

There is large potential for interventions to improve patient well-being in the pre-hospital setting and emergency department. Given the sizable number of patients with poor outcomes, palliative care is also of paramount importance.

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.

Caring science research in the ambulance services: an integrative systematic review

BACKGROUND

The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings.

AIM

This integrative systematic review aims to describe caring science research content and scope in the ambulance services.

DATA SOURCES

Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156.

REVIEW METHODS

The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five-stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3-level scale, and data relevance was evaluated on a 2-level scale.

RESULTS

After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision-making; Public environment and patient safety; Life-changing situations; and Ethics and values.

CONCLUSION

Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional-patient relation, with special focus on value conflicts in emergency situations.

Paramedics providing palliative care at home: A mixed-methods exploration of patient and family satisfaction and paramedic comfort and confidence

OBJECTIVE

Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.

METHODS

In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.

RESULTS

In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.

CONCLUSIONS

After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

Paramedics’ perceptions of Their Role in Palliative Care: Analysis of Focus Group Transcripts

Paramedics play an important role in out-of-hospital health care. They provide unscheduled care, assisting both patients with minor injuries and those experiencing life-threatening emergencies. Increasingly, paramedics are called on to manage chronic and complex health needs, including symptom relief for patients at the end of life. However, paramedics may not be well prepared to offer palliative care, as practice guidelines and education tend to focus on the management of acute medical emergencies and major trauma. Emergency medical services that employ paramedics rarely have practice guidelines or protocols that deal specifically with palliative care.

Palliative patients under anaesthesiological care: a single-centre retrospective study on incidence, demographics and outcome

BACKGROUND

While anesthesiologist's involvement in palliative care has been widely researched, extensive data on palliative patients under anesthesiological care in the operating room is missing. This study was performed to assess the incidence, demographics, and outcome of palliative patients under anesthesiological care.

METHODS

We conducted a single-center retrospective chart review of all palliative patients under anesthesiological care at a university hospital in 1 year. Patients were classified as palliative if they fulfilled all predefined criteria (a) incurable, life-threatening disease, (b) progression of the disease despite therapy, (c) advanced stage of the disease with limited life-expectancy, (d) receiving or being in need of a specific palliative therapy. Demographics, periprocedural parameters, symptoms at evaluation, and outcome were determined using different medical records.

RESULTS

Of 17,580 patients examined, 276 could be classified as palliative patients (1.57%). Most contacts with palliative patients occurred in the operating room (68.5%). In comparison to the non-palliative patients, procedures in palliative patients were significantly more often urgent or emergency procedures (39.1% vs. 27.1%., P < 0.001), and hospital mortality was higher (18.8% vs. 5.0%, P < 0.001). Preprocedural symptoms varied, with pain, gastrointestinal, and nutritional problems being the most prevalent.

CONCLUSIONS

Palliative patients are treated by anesthesiologists under varying circumstances. Anesthesiologists need to identify these patients and need to be aware of their characteristics to adequately attend to them during the periprocedural period.

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.

Are emergency admissions in palliative cancer care always necessary? Results from a descriptive study

OBJECTIVES

Patients with advanced cancer are often admitted to hospital as emergency cases. This may not always be medically indicated. Study objectives were to register the reasons for the emergency admissions, to examine interventions performed during hospitalisation and self-reported symptom intensity at admission and discharge, and to assess patients' opinions about the admission.

DESIGN

This was a descriptive before-and-after study. Participating patients completed the Edmonton Symptom Assessment System (ESAS) twice, upon hospital admission and prior to discharge. All patients underwent a structured interview assessing their opinion about the emergency admission. Medical data were obtained from the hospital records.

SETTING

The study was performed in two Norwegian acute care secondary hospitals with urban catchment areas.

PARTICIPANTS

44 patients with cancer (men 27 and women 17; mean age 69.2, SD 9.2) representing 50 emergency admissions were included.

RESULTS

Median length of stay was 7 days (95% CI 7.4 to 11.4). Median survival was 50 days (95% CI 51 to 115). 90% were admitted from home, and 46% had been hospitalised less than 1 month earlier. Lung and gastrointestinal symptoms and pain were the most frequent reasons for admissions. Mean pain scores on ESAS were reduced by 50% from admission to discharge (p<0.01). Simple interventions such as hydration, bladder catheterisation and oxygen therapy were most frequent. Nearly one-third would have preferred treatment at another site, provided that the quality of care was similar. Home visits by the family doctor and specialised care teams were perceived by patients as important to prevent hospitalisation.

CONCLUSIONS

In most emergency admissions, relatively simple medical interventions are necessary. Specialised care teams with palliative care physicians, easier access to the family doctor and better lines of cooperation between hospitals and the primary care sector may make it possible to perform more of these procedures at home, thereby reducing the need for emergency admissions.

Emergencies in patients with advanced cancer followed at home

CONTEXT

Patients with advanced cancer stay at home for most of their time, and acute problems may occur during home care. Caregivers may call medical services for an emergency, which can result in patients being admitted to the hospital. No data exist on emergencies in patients followed by a home care team.

OBJECTIVES

The aim of this multicenter prospective study was to assess the frequency, reasons for, and subsequent course of emergency calls for patients followed at home by a palliative care team.

METHODS

A consecutive sample of patients admitted to home care programs was surveyed for a period of seven months. Epidemiological data, and characteristics of emergency calls and outcomes, as well as environmental situations were recorded.

RESULTS

Six hundred eighty-nine patients were surveyed; 118 patients (17.1% of the total number of patients surveyed) made one emergency call, 23 made two calls, and four made three calls for a total number of 176 emergency calls. The mean age was 71 years (standard deviation [SD] 13), and the mean Karnofsky status the day before the emergency call was 38 (SD 14). The mean time from admission to the first emergency call was 38.4 days (SD 67), and the mean time from the first emergency call to death was 17.5 days (SD 41.5). No differences were found for age, diagnosis, gender, duration of assistance, and survival between patients making emergency calls and those who did not make a call during an emergency. Twenty-three patients were managed by phone, and 122 were visited at home for the emergency. Calls were prevalently recorded on weekdays and were primarily made by relatives. The most frequent reasons for calling were dyspnea, pain, delirium, and loss of consciousness. Calls were considered justified by home care physicians in most cases. The mean number of relatives present during the emergency home visit was 2.2 (SD 1.5). The intervention was mainly pharmacological and considered satisfactory in the majority of cases.

CONCLUSION

Emergency calls are relatively frequent in patients followed at home by a palliative care team. Phone consultation or intervention at home may avoid inappropriate hospital admission.

[Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care]

BACKGROUND

At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients.

METHODS

For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources.

RESULTS

As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment.

CONCLUSIONS

Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary.

Palliative care and involvement of anaesthesiology: current discussions

PURPOSE OF REVIEW

To summarize various developments related to palliative care, especially related to ethical issues. To emphasize the involvement of anaesthesiology in palliative care.

RECENT FINDINGS

Euthanasia has been legalized in Belgium, the Netherlands and Luxemburg (BENELUX countries). A group from Belgium has now proposed using euthanasia in patients in whom palliative care has been deemed 'futile'. This practice of so-called 'integral palliative care' is strongly rejected in a study from Germany. Palliative sedation is an ethically different approach with no intention to kill the patient. The European Association of Palliative Care has proposed a framework for individual guidelines for palliative sedation. The important role of anaesthesiology in palliative care teams is emphasized.

SUMMARY

Palliative care is a powerful approach to patient care during terminal illness, emphasizing quality of life even if it may shorten the length of life. Traditionally, palliative care has been contrasted with active euthanasia, but a group from Belgium has challenged this concept recently, advocating the use of euthanasia in circumstances in which palliative care has become 'futile'. This new approach led to strong reactions by a group from Germany, stressing that killing on demand in palliative care should under no circumstances be justified. In contrast, palliative sedation is a common method in special cases to reduce intractable symptoms. A new framework for palliative sedation produced by the European Association of Palliative Care may encourage institutions to set up their own palliative sedation guidelines. Worldwide, anaesthesiologists have a significant role in palliative care due to their unique complex expertise mainly in pain therapy and including transient sedation of patients.

[Emergency medical treatment of palliative care patients at the end of life: regulatory emergency medical care framework--a case control investigation of medical intervention and advance directives]

BACKGROUND

The treatment of out-of-hospital palliative emergency care situations during cardiac arrest is a special situation. The prehospital emergency physician (EP) and the paramedic must be informed about the medical, legal, and ethical specifics of these situations, but this knowledge is not integrated within emergency medical curricula at all. We present a case study to discuss such legal and ethical specifics.

METHODS

We retrospectively analysed six emergency cases with palliative care patients in the final stages of their illnesses. On the basis of these case studies, we present six different emergency cases with different regulatory frameworks for each EP and paramedic. In accordance with the Declaration of Helsinki, data were collected pseudonymously.

RESULTS

The six case studies show therapeutic concepts concerning the emergency medical care of palliative care patients during cardiac arrest. The differences are apparent in the treatment given by EPs and by paramedics (such as whether to start or stop resuscitation). EPs and paramedics differ in their therapeutic approach to these specific situations (e.g. paramedics more often start resuscitation during cardiac arrest even though patients would refuse this according to their advance directives). These differences may be important for the patient and his or her caregivers.

CONCLUSIONS

Every EP and paramedic may be involved in the care of palliative care patients who are at the end of their lives. EPs and paramedics do not always adapt their treatment to the will or supposed will of the patient (especially in accordance with the new German law concerning advance directives). The reasons for this usually concern legal uncertainties. Therefore, EPs and paramedics should know that different legal meanings could be important in emergency medical care therapy of palliative care patients. A written "do not resuscitate" order as an advance directive must be evaluated as a desired therapeutic limitation.