Mapping the future for research in emergency medicine palliative care: A research roadmap.

BACKGROUND: The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE: The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS: Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS: Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS: There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Feasibility and Acceptability of Inpatient Palliative Care E-Family Meetings During COVID-19 Pandemic.

Family meetings are fundamental to the practice of palliative medicine and serve as a cornerstone of intervention on the inpatient palliative care consultation service. The COVID-19 pandemic disrupted the structure and process of in-patient family meetings, owing to necessary but restrictive visitor policies that did not allow families to be present in the hospital. We describe implementation of telemedicine to facilitate electronic family (e-family) meetings to facilitate in-patient palliative care. Of 67 scheduled meetings performed by the palliative care service, only two meetings were aborted for a 97% success rate of scheduled meetings occurring. On a five-point Likert-type scale, the average clinician rating of the e-family meeting overall quality was 3.18 (SD, .96). Of the 10 unique family participants who agreed to be interviewed, their overall ratings of the e-family meetings were high. Over 80% of respondent families participants reported that they agreed or strongly agreed that they were able to ask all of their questions, felt comfortable expressing their thoughts and feelings with the clinical team, felt like they understood the care their loved one received, and that the virtual family meeting helped them trust the clinical team. Of patients who were able to communicate, 50% of family respondents reported that the e-family meeting helped them understand their loved one's thoughts and wishes.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients in the Emergency Department.

Palliative principles are increasingly within the scope of emergency medicine (EM). In EM, there remain untapped opportunities to improve primary palliative care (PC) and integrate patients earlier into the palliative continuum. However, the emergency department (ED) differs from other practice environments with its unique systemic pressures, priorities, and expectations. To build effective, efficient, and sustainable partnerships, palliative clinicians are best served by understanding the ED's practice priorities. The authors, each EM and Hospice and Palliative Medicine board certified and in active practice, present these 10 high-yield tips to optimize the ED consultation by PC teams.

The Palliative Performance Scale Predicts Three- and Six-Month Survival in Older Adult Patients Admitted to the Hospital through the Emergency Department.

BACKGROUND: There is often little information on long-term prognosis available for Emergency Medicine physicians when decisions on admission, treatment, or consultations are being made for patients. There is a new focus to understand if palliative support should be offered in the emergency department (ED) and the Palliative Performance Scale (PPS), a screening tool used in other settings in palliative care, has been little used in the ED. OBJECTIVE: The goal of this study was to assess the prognostic value of the PPS in predicting three- and six-month survival in patients admitted through the ED. DESIGN: A prospective cohort study. SETTING/SUBJECTS: We evaluated 123 patients over the age of 55 years admitted through the ED of a tertiary care hospital in New England in November and December of 2013. MEASUREMENTS: Each patient's PPS score was evaluated initially in the ED, with follow-up assessments of PPS and survival at three and six months. RESULTS: Baseline PPS for the 123 patients was 72 ± 22. Information on 72 subjects (58.5%) at three months was 60 assessed and 12 deaths. Information on 47 subjects (38.2%) at six months was 26 assessed and 21 deaths (nine further deaths from three months). There were no significant differences in the demographics or PPS score in those evaluated and those lost to follow-up at three or six months. Patients with an initial PPS score of 30 or less had 14% survival at six months. CONCLUSION: In this small preliminary study, The PPS score may predict survival in patients admitted to the hospital through the ED. The ease of use holds promise that use of the PPS in the ED may help ED physicians predict survival and plan for better disposition, advocate for patient wishes, and initiate palliative care consultation.

EM Talk: communication skills training for emergency medicine patients with serious illness.

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.

Acute thrombotic disorders.

The acquired hypercoagulable states are responsible for a broad range of thrombotic and thromboembolic disorders. Symptoms and signs of acute ischemia or organ dysfunction will lead many of these patients to seek care in EDs. Proper diagnosis and therapy must be based on an understanding of epidemiology and pathophysiology. Immediate anticoagulation with heparin may not always be the treatment of choice; careful analysis of clinical and laboratory parameters is necessary to arrive at the safest and most effective course of action. Newer anticoagulants, including low-molecular-weight heparins and nonheparin compounds, are changing the therapeutic approach to many of these disorders.