Lessons from the Literature

2019; Volume 20, No 12, December

Lessons from the Literature

Under My Microscope

Dr. Tania Pastrana. Used with permission.

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Prevalence of Palliative Care Patients in Emergency Departments

Markus Köstenberger, Stefan Neuwersch, Dietmar Weixler, Wolfgang Pipam, Michael Zink, and Rudolf Lika. Wien Klin Wochenschr 2019; 131(17-18): 404-409.

DOI: 10.1007/s00508-019-1530-5

The palliative care model has changed from a palliative care service that focused mainly on end-stage cancer patients to one that is much more inclusive, involving people with many diseases, even those who are not at the end of life. It has transitioned from a specialist service to one available in all settings of health and social care.1 This movement has caused palliative care to build alliances with other specialties.

It is known that many cancer patients in the last months and weeks of life are seen and treated in emergency departments (EDs). 2, 3 An Austrian team of researchers, led by Köstenberger, conducted a retrospective study of patients who visited the ED to determine the prevalence of patients with palliative care needs. The study also determined if those patients received palliative care.

Patients were classified on arrival with the Manchester triage system and were screened with a palliative care screening tool.4 The researchers identified palliative needs in more than one in 10 (13%) of the patients; however, only 5.5% of the patients in need received palliative care. Almost 40% of these patients were classified as “urgent” or “very urgent.”

This study shows that the integration of palliative care in the ED is an urgent and necessary alliance.

References

1. IAHPC. Consensus-based definition of palliative care. 2019.
2. Wong J, Gott M, Frey R, et al. What is the incidence of patients with palliative care needs presenting to the emergency department? A critical review. Palliat Med 2014; 28(10): 1197-2056.
DOI: 10.1177/0269216314543318.
3. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010; 182(6): 563-568.
DOI: 10.1503/cmaj.091187.
4. George N, Barrett N, McPeake L, et al. Content validation of a novel screening tool to identify emergency department patients with significant palliative care needs. Acad Emerg Med 2015; 22(7): 823-837.
DOI: 10.1111/acem.12710.

Background: Emergency departments (EDs) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far.

Methods: In the ED of a tertiary care medical center in Carinthia all adult patients presenting between January 8, 2018, and January 17, 2018, were classified on arrival with the Manchester Triage System (MTS) and were afterwards assessed with a validated twotier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care.

Results: In total, 1,277 patients visited the ED during the investigation period. Of these patients, 1,096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only eight (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation.

Conclusions: More than one in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that health care providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.


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Media Watch: The Homeless

The plight of the homeless is gaining increased attention, indicative of worldwide efforts to address the needs of this particularly vulnerable population. In Canada alone, more than 235,000 people experience homelessness in a year. The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.

Barriers to End-of-Life Services for Persons Experiencing Homelessness as Perceived by Health and Social Service Providers

Journal of the American Board of Family Medicine, 2019; 32(6): 847-857. People experiencing homelessness have significantly shorter life expectancies and higher rates of morbidity and mortality than the general population. Many barriers have been identified to providing palliative care (PC) to this population. Participants in this study approached the end-of-life care (EoLC) of people experiencing homelessness from a framework of dignity and respect. Themes included: barriers to EoLC internal to the health care system; care avoidance; the experience of stigma for this population when accessing EoLC; lack of provider information and awareness on how to provide care for marginalized groups, how to provide care in the context of substance use, and how to assist clients in accessing the formal PC system; and, the need for harm reduction approaches to EoLC for persons experiencing homelessness. Focusing on harm reduction, and using the framework of Equity-Oriented Health Care to make systemic, cultural, and policy changes to develop a PC system for persons experiencing homelessness may improve care experience for both patients and providers.

DOI: 10.3122/jabfm.2019.06.190066

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Experiences of Palliative Health Care for Homeless and Vulnerably Housed Individuals

Journal of the American Board of Family Medicine, 2019; 32(6): 858-867. The authors’ findings provide a roadmap for the development, implementation, and evaluation of palliative care services that would be available, accessible, and acceptable to some of the most vulnerable in our community, using their voices to guide our efforts. Study participants’...desires echoed what others have said in the literature. Participants challenge health care providers to question their own paradigms, and to ensure that they provide care that is patient centered, non-stigmatizing, and non-discriminatory; care that embraces principles of harm reduction, flexibility, dignity, and autonomy; care that is provided outside of hospitals, either in institutions that feel as much as possible like a home, or on the street in an outreach setting for clients who are either not ready or not willing to be in an institution; care that is informed by, and to some extent provided by, people with lived experience; care that is equity-oriented and equity-enhancing for all.

DOI: 10.3122/jabfm.2019.06.190093

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“Just too busy living in the moment and surviving”: Barriers to accessing health care for structurally vulnerable populations at end of life

BMC Palliative Care | Online – 26 January 2018 –This study contributes a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Insights [in this article] make visible the gaps in service provision, and provide information for service providers and policy decision-makers on ways to enhance the equitable provision of EoL care for all populations.

DOI: 10.1186/s12904-019-0396-7

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Palliative Care for Homeless Patients: A practical approach for medical students

University of Toronto Medical Journal, 2019; 96(3): 83-84. It is important to be well informed about the unique issues facing homeless patients who may benefit from palliative care (PC) before engaging with these populations. Gathering knowledge and skills should always begin with consulting the literature, but can also involve attending talks, volunteering in the community, and Twitter... [A] practical measure of readiness for working with vulnerable populations is self-assessed efficacy... Dr. Naheed Dosani, the founder of the Palliative Education & Care for the Homeless program, believes it is important to keep the foundations of your potential idea rooted in evidence and expert opinion, but also to incorporate the lived experiences of the patients whom you are endeavouring to help.

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.


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