Interprofessional Master of Science in Palliative Care: On Becoming a Palliative Care Community Specialist.

Background: Palliative care (PC) is a limited resource in health care systems. Many providers develop a PC interest later in their careers when it is difficult to relocate and compete for a limited number of training positions. In communities without an academic tertiary medical center, interprofessional PC community specialists are poised to deliver high-quality accessible PC to patients/families with needs beyond what can be addressed by primary care providers. Objective: An interprofessional 36-credit Master of Science in Palliative Care (MSPC) provides evidence-based education to nurses, pharmacists, physicians, physician assistants, social workers, spiritual care providers, psychologists, counselors, and other allied health professionals. Design: The predominantly online curriculum, designed and taught by an interprofessional faculty, focuses on interdisciplinary teamwork, communication skills, and practical application of biomedical and psycho-sociocultural-spiritual-ethics content. The pedagogy is narrative based, emulating in-person clinical experiences, with patient cases progressing throughout the curriculum. We have enrolled four student cohorts. Measurements: Student self-assessments pre-mid-post program. Results: Students highly rate curriculum with demonstrated application of knowledge in case integration assignments, simulations with standardized patients, and Capstone Projects. Students' self-assessed skills on a 39-item scale increased on average to the highest level of 5 (able to perform independently and teach others). Conclusions: The inaugural student cohort reports high levels of engagement and satisfaction, including mastery and synthesis of didactic and experiential content through case integration projects. Students who worked in PC/hospice settings have advanced in their professions; others have transitioned to PC work. The MSPC has capacity to meet projected PC workforce gaps.

Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge.

Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best-practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision-making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired. We present two cases that illustrate key insights into a best-practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients.

Frequent users of US emergency departments: characteristics and opportunities for intervention.

OBJECTIVE: To compare the characteristics of US adults by frequency of emergency department (ED) utilisation, specifically the prevalence of chronic diseases and outpatient primary care and mental health utilisation. METHODS: We analysed 157 818 adult participants of the 2004-2009 US National Health Interview Survey, an annual nationally representative sample. We defined ED utilisation during the past 12 months as non-users (0 ED visits), infrequent users (1-3 visits), frequent users (4-9 visits) and super-frequent users (≥10 visits). We compared demographic data, socioeconomic status, chronic diseases and access to care between these ED utilisation groups using multivariable logistic regression. RESULTS: Overall, super-frequent use was reported by 0.4% of US adults, frequent use by 2% and infrequent ED use by 19%. Patients reporting ≥4 ED visits were more likely to have Medicaid insurance (OR 1.57; 95% CI 1.34 to 1.85 vs private); fair or poor self-reported health (OR 2.98; 95% CI 2.57 to 3.46 vs excellent-very good); and chronic diseases such as coronary artery disease (OR 1.61; 95% CI 1.40 to 1.86), stroke (OR 1.58; 95% CI 1.36 to 1.83) or asthma (OR 1.64; 95% CI 1.46 to 1.85). While patients reporting the ED as their usual source of sick care were more likely to have ≥4 ED visits (OR 7.09; 95% CI 5.61 to 8.95 vs outpatient clinic as source), ≥10 outpatient visits in the past 12 months was also associated with frequent ED use (OR 11.4; 95% CI 9.09 to 14.2 vs no outpatient visits). CONCLUSIONS: Frequent ED users had a large burden of chronic diseases that also required high outpatient resources. Interventions designed to divert frequent ED users should focus on chronic disease management and access to outpatient services, particularly for Medicaid beneficiaries and other high risk subpopulations.

Uterine trauma in pregnancy after motor vehicle crashes with airbag deployment: A 30-case series.

BACKGROUND: We describe a cohort of women of at least 20 weeks gestation to determine the frequency of placental abruption or fetal compromise after a motor vehicle crash (MVC) with airbag deployment. METHODS: A retrospective chart review was conducted at two urban emergency departments. All women of at least 20 weeks gestation with MVCs in which their airbag deployed and who were admitted for monitoring or trauma care between 1997 and 2002 were identified by the Trauma Registry for each hospital and included. RESULTS: Thirty women in the 6-year period were identified. Gestational age (GA) at the time of the MVC ranged from 20 weeks to 37 weeks (median GA 29 weeks). Of the 30 women, 15 (50%) were belted drivers, 5 (17%) were unbelted drivers, 5 (17%) were belted front-seat passengers, and 5 (17%) were unbelted front-seat passengers. Median speed was 35 mph. One woman experienced placental abruption with subsequent intrauterine fetal demise. Twenty-two (73%, 95% CI: 58-89) experienced uterine contractions. Sixteen (53%, 95% CI: 36-71) reported abdominal pain. Abnormal fetal heart rate was documented in six patients (20%, 95% CI: 6-34). Vaginal bleeding was reported in two patients (7%). Only three women had no abnormal abdominal findings after the MVC. CONCLUSIONS: From this preliminary series, placental abruption does not appear to occur frequently in MVCs with airbag deployment. It is unclear if fetal risk is higher than that without airbags. A significant number of pregnant women do not wear seatbelts.

Confronting the ethical challenges to informed consent in emergency medicine research.

The Society for Academic Emergency Medicine believes that protection of human subjects is vital in emergency medicine research and that, whenever feasible, informed consent is at the heart of that protection. At the same time, the emergency setting presents unique barriers to informed consent both because of the time frame in which the research is performed and because patients in the emergency department are a vulnerable population. This report reviews the concept of informed consent, empirical data on patients' cognitive abilities during an emergency, the federal rules allowing exemption from consent under certain circumstances, issues surrounding consent forms, and the new Health Insurance Portability and Accountability Act regulations as they relate to research. The authors conclude that, in many circumstances, informed consent is possible if the researcher is diligent and takes time to adequately explain the study to the potential subject. In cases in which it is possible to obtain consent, precautions must be taken to ensure that subjects have decision-making capacity and are offered time to have their questions answered and their needs met. Sometimes resuscitation and other emergency medicine research must be conducted without the ability to obtain consent. In these cases, special protections of subjects under the exception from consent guidelines must be followed. Protection of research subjects is the responsibility of every researcher in emergency medicine.

Ethics seminars: the ethical debate on practicing procedures on the newly dead.

Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.