Emergency medicine physicians' perspectives of providing palliative care in an emergency department.

This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

The palliative care model for emergency department patients with advanced illness.

BACKGROUND: Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). DISCUSSION: Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition. CONCLUSION: Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

"I want to be taking my own last breath": patients' reflections on illness when presenting to the emergency department at the end of life.

OBJECTIVE: To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life. METHODS: Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results. RESULTS: Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences. CONCLUSIONS: Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

Perspectives from the other side: a physician and cancer survivor.

ASCO has made great strides to integrate palliative care into the comprehensive care model. However, much work remains to ensure that all patients, whether receiving curative or palliative therapy, have a good quality of life.

The intersection of need and opportunity: assessing and capitalizing on opportunities to expand hospital-based palliative care services.

BACKGROUND: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact. SUBJECTS AND METHODS: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.

Treatment preferences: impact of risk and benefit in decision-making.

Understanding treatment preferences of seriously ill patients is complex. Previous studies have shown a correlation between the burden and outcome of a treatment and the likelihood a patient will accept a given intervention. In this study the Willingness to Accept Life Sustaining Treatment (WALT) survey was used in a predominantly Latino population receiving care at a large urban safety net hospital. Eligible patients were cared for by one of four clinics: (1) human immunodeficiency virus (HIV); (2) geriatrics; (3) oncology; or (4) cardiology. Hypothetical scenarios reflecting outcomes of resuscitation were presented and patients were given information on the burden and outcome of treatment. They were then given the option of accepting or declining treatment; 237 completed the survey. Patients in our study were willing to accept a high level of cognitive (vegetative state) and functional (bed-bound) impairment even when the chance of recovery was exceedingly low.

Paramedic knowledge, attitudes, and training in end-of-life care.

INTRODUCTION: Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills. METHODS: A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under- or over-preparation. RESULTS: Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22-59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91-97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52-65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96-100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20-32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26-43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23-38%); and (3) verbal ADs (75% very important vs. 54%well-prepared, difference 21%: 95% CI = 12-29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23-39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation. CONCLUSIONS: There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

IFN-gamma is the only anti-rotavirus cytokine found after in vitro stimulation of memory CD4+ T cells from mice immunized with a chimeric VP6 protein.

CD4+ T cells are the only lymphocytes required for protection of mice against rotavirus shedding after mucosal immunization with chimeric VP6 (MBP::VP6) and the adjuvant LT(R192G). One possible effector of protection is CD4+ T-cell cytokines. To determine if memory CD4+ T cells of immunized mice produce cytokines with direct anti-rotavirus activity, an in vitro infection model was developed using mouse CMT-93 cells and rhesus rotavirus (RRV). Spleen and lamina propria (LP) cells, as well as purified splenic CD4T cells obtained after intranasal immunization of BALB/c mice with MBP::VP6/LT(R192G) released large quantities of two cytokines (IL-17 and IFN-gamma) into cell supernatants when stimulated with MBP::VP6. Production of these same cytokines is rapidly upregulated in intestinal lymphocytes after rotavirus inoculation of immunized mice. IL-17 pretreatment of CMT-93 cells had no effect on subsequent RRV replication, but IFN-gamma was the most potent inhibitor within a panel of nine cytokines tested. Supernatants obtained after in vitro stimulation of splenic CD4+ T cells of immunized mice had high levels of anti-RRV activity and their pretreatment with mAb against IFN-gamma caused essentially complete loss of activity. Thus, IFN-gamma was the only cytokine identified in stimulated CD4+ T cells from immunized mice that directly inhibited rotavirus replication.

Mice develop effective but delayed protective immune responses when immunized as neonates either intranasally with nonliving VP6/LT(R192G) or orally with live rhesus rotavirus vaccine candidates.

Rotavirus vaccines are delivered early in life, when the immune system is immature. To determine the effects of immaturity on responses to candidate vaccines, neonatal (7 days old) and adult mice were immunized with single doses of either Escherichia coli-expressed rotavirus VP6 protein and the adjuvant LT(R192G) or live rhesus rotavirus (RRV), and protection against fecal rotavirus shedding following challenge with the murine rotavirus strain EDIM was determined. Neonatal mice immunized intranasally with VP6/LT(R192G) were unprotected at 10 days postimmunization (dpi) and had no detectable rotavirus B-cell (antibody) or CD4(+) CD8(+) T-cell (rotavirus-inducible, Th1 [gamma interferon and interleukin-2 {IL-2}]-, Th2 [IL-5 and IL-4]-, or ThIL-17 [IL-17]-producing spleen cells) responses. However, by 28 and 42 dpi, these mice were significantly (P >or= 0.003) protected and contained memory rotavirus-specific T cells but produced no rotavirus antibody. In contrast, adult mice were nearly fully protected by 10 dpi and contained both rotavirus immunoglobulin G and memory T cells. Neonates immunized orally with RRV were also less protected (P=0.01) than adult mice by 10 dpi and produced correspondingly less rotavirus antibody. Both groups contained few rotavirus-specific memory T cells. Protection levels by 28 dpi for neonates or adults were equal, as were rotavirus antibody levels. This report introduces a neonatal mouse model for active protection studies with rotavirus vaccines. It indicates that, with time, neonatal mice develop full protection after intranasal immunization with VP6/LT(R192G) or oral immunization with a live heterologous rotavirus and supports reports that protection depends on CD4(+) T cells or antibody, respectively.

Protection against rotavirus shedding after intranasal immunization of mice with a chimeric VP6 protein does not require intestinal IgA.

Intranasal immunization of mice with chimeric VP6 and the adjuvant LT(R192G) consistently elicits >95% reductions in fecal rotavirus shedding following challenge. To determine the association between mucosal antibody and protection, we immunized BALB/c wt and J chain knockout (Jch-/-) mice with VP6 and either LT(R192G) or cholera toxin (CT). Both strains developed nearly equal levels of serum rotavirus IgG, but Jch-/- mice, which cannot transport dimeric IgA across epithelial cell surfaces, developed >4-fold higher levels of serum rotavirus IgA. Stool rotavirus IgA was present in wt but undetectable in Jch-/- mice. When challenged with rotavirus strain EDIM, reductions in rotavirus shedding were nearly identical in VP6-immunized wt and Jch-/- mice (i.e., 97% and 92%, respectively; P > 0.01). Th1 CD4 T cell responses were also detected in VP6-immunized animals based on high levels of IFN-gamma and IL-2 found after in vitro VP6 stimulation of spleen cells. Therefore, protection induced by intranasal immunization of mice with VP6 and adjuvant does not depend on intestinal rotavirus IgA antibody but appears to be associated with CD4 T cells.

Emphysematous pyelonephritis: clues to rapid diagnosis in the Emergency Department.

Emphysematous pyelonephritis (EPN) is an acute life-threatening bacterial infection. EPN leads to rapid necrotizing destruction of the renal parenchyma and peri-renal tissue, requiring early and aggressive care to reduce morbidity and mortality. Previous studies have described the use of computed tomography scan and radiology-performed ultrasound to make the diagnosis of EPN We report a case of EPN diagnosed by bedside Emergency Department (ED) ultrasound performed by emergency physicians, allowing a more rapid diagnosis and subsequent treatment.

Pneumococcal vaccination in the emergency department: an assessment of need.

STUDY OBJECTIVES: Immunization against Streptococcus pneumoniae with the 23-valent pneumococcal polysaccharide vaccine has been shown to be cost-effective for prevention of invasive pneumococcal disease. Yet 23-valent pneumococcal polysaccharide vaccine is widely underused, particularly among ethnic minorities. The objectives of this survey are to determine the rate of 23-valent pneumococcal polysaccharide vaccine vaccination among all adult patients presenting to the emergency department (ED) of a county-based, urban, tertiary care medical center; the willingness of patients to receive 23-valent pneumococcal polysaccharide vaccine; and reasons for nonvaccination. METHODS: A quality assurance survey was performed in the ED during 3 days in September 2002. A survey was developed to determine 23-valent pneumococcal polysaccharide vaccine vaccination rates and eligibility according to indications and contraindications established by the Centers for Disease Control and Prevention (CDC). Descriptive statistics were performed to quantify the proportion of patients who were immunized, eligible, and willing to receive 23-valent pneumococcal polysaccharide vaccine and reasons for nonvaccination. RESULTS: A total of 250 patients of 1,535 registered in the ED were surveyed during the 3-day period. Only 48 (19%) had a primary care provider. The majority of patients were Hispanic (73%). Only 22 (9%) patients had received the vaccine. A total of 66 (26%) patients fit the CDC eligibility criteria for 23-valent pneumococcal polysaccharide vaccine, and 59 (89%) of these patients were willing to receive the vaccine during their ED visit. Most patients (79%) were eligible to receive 23-valent pneumococcal polysaccharide vaccine due to their comorbid illnesses. CONCLUSION: In the ED of our county-based urban medical center, 26% of patients were eligible for 23-valent pneumococcal polysaccharide vaccine; the majority of patients were Hispanic, unaware of the vaccine's existence, and willing to receive it during their ED visit. These data underscore a large unmet public health need among ethnic minorities in the ED.

Intranasal or oral immunization of inbred and outbred mice with murine or human rotavirus VP6 proteins protects against viral shedding after challenge with murine rotaviruses.

Intranasal (i.n.) administration of an Escherichia coli-expressed chimeric VP6 protein from the EDIM strain of murine rotavirus to adult BALB/c (H-2(d)) mice along with LT(R192G), an attenuated mutant of the mucosal adjuvant E. coli heat-labile toxin, has been found to consistently stimulate ca. 99% reductions in rotavirus shedding after subsequent EDIM challenge. This study was designed to determine the robustness of this protection, i.e. can VP6 immunization consistently protect against shedding in this model, thus, providing an indication of its potential as a vaccine. Intranasal immunization with two 8.8 microg doses of EDIM VP6 and 10 microg of LT(R192G) was found to stimulate 99% reductions in EDIM shedding in four additional strains of inbred mice belonging to three haplotypes, i.e. DBA/2 (H-2(d)), C57BL/6 (H-2(b)), 129 (H-2(b)) and C3H (H-2(k)). Protection stimulated against EDIM antigen shedding following i.n. immunization with VP6 from the human CJN strain was less (P=0.02) than induced by EDIM VP6 (86% versus 99%), but no further loss of protection was observed when the dose of CJN VP6 was reduced 100-fold. Protection against EDIM shedding was also maintained after i.n. immunization of three strains of outbred mice (CF-1, CD-1 and Swiss Webster) with either EDIM or CJN VP6, i.e. EDIM VP6 immunization reduced EDIM shedding by 99% while CJN VP6 immunization produced reductions of 86-96%. Protection stimulated by oral immunization of BALB/c mice with two 8.8 microg doses of either VP6 chimera plus LT(R192G) was not significantly different from that induced by i.n. immunization. Finally, protection found after either oral or i.n. immunization with EDIM or CJN VP6 was no different when the mice were challenged with McN, another strain of murine rotavirus. These results support further evaluation of VP6 as a vaccine.

CD4 T cells are the only lymphocytes needed to protect mice against rotavirus shedding after intranasal immunization with a chimeric VP6 protein and the adjuvant LT(R192G).

Intranasal immunization of mice with a chimeric VP6 protein and the mucosal adjuvant Escherichia coli heat labile toxin LT(R192G) induces nearly complete protection against murine rotavirus (strain EDIM [epizootic diarrhea of infant mice virus]) shedding for at least 1 year. The aim of this study was to identify the protective lymphocytes elicited by this new vaccine candidate. Immunization of mouse strains lacking one or more lymphocyte populations revealed that protection was dependent on alphabeta T cells but mice lacking gammadelta T cells and B cells remained fully protected. Furthermore, depletion of CD8 T cells in immunized B-cell-deficient mice before challenge resulted in no loss of protection, while depletion of CD4 T cells caused complete loss of protection. Therefore, alphabeta CD4 T cells appeared to be the only lymphocytes required for protection. As confirmation, purified splenic T cells from immunized mice were intraperitoneally injected into Rag-2 mice chronically infected with EDIM. Transfer of 2 x 10(6) CD8 T cells had no effect on shedding, while transfer of 2 x 10(5) CD4 T cells fully resolved shedding in 7 days. Interestingly, transfer of naive splenic CD4 T cells also resolved shedding but more time and cells were required. Together, these results establish CD4 T cells as effectors of protection against rotavirus after intranasal immunization of mice with VP6 and LT(R192G).