Am I Doing the Right Thing? Provider Perspectives on Improving Palliative Care in the Emergency Department - 14/09/13

Doi : 10.1016/j.annemergmed.2008.08.022

Alexander K. Smith, MD, MS, MPH ^a,^c,^{^{1
Dr. Smith is now with Division of Geriatrics, University of California, San Francisco, San Francisco, CA.},}^⁎ , Jonathan Fisher, MD ^b, Mara A. Schonberg, MD, MPH ^a, Daniel J. Pallin, MD, MPH ^d, Susan D. Block, MD ^c, Lachlan Forrow, MD ^a, Russell S. Phillips, MD ^a, Ellen P. McCarthy, PhD, MPH ^a
^a Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
^b Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
^c Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
^d Department of Emergency Medicine, Brigham and Women's Hospital, and Division of Emergency Medicine, Children's Hospital Boston, Boston, MA

Address for correspondence: Alexander K. Smith, MD, MS, MPH, Division Geriatrics, UCSF, 4150 Clement St (181G), San Francisco, CA 94121; 415-221-4810 extension 4684, fax: 415-750-6641

Résumé

Study objective

Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods.

Methods

We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus.

Results

Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patient's family and written advance directives); and (6) training in pain management is inadequate.

Conclusion

Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.

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Plan

Introduction

Materials and Methods

Study Design

Data Collection and Processing

Primary Data Analysis

Results

Limitations

Discussion

	Provide process.asp?qs_id=4410 on this article at the journal's Web site, www.annemergmed.com.
	Supervising editor: Rita K. Cydulka, MD, MS
	Author contributions: AKS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. AKS, JF, MAS, DJP, SDB, LF, RSP, and EPM were responsible for study concept and design and revision of the article for important intellectual content. AKS acquired the data. AKS, JF, and MAS were responsible for analysis and interpretation of data. AKS drafted the article. LF obtained funding. AKS supervised the study. AKS takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was performed in its entirety while Dr. Smith was a general medicine fellow at Beth Israel Deaconess Medical Center. This research was supported by The Julie Henry Fund at Beth Israel Deaconess Hospital. Dr. Smith was supported by an institutional National Research Service Award, #5 T32 HP11001-19.
	Publication date: Available online October 18, 2008.
	Reprints not available from the authors.