End-of-life issues: Withdrawal and withholding of life-sustaining healthcare in the emergency department: A comparison between emergency physicians and emergency registrars: A sub-study.

OBJECTIVE: We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER). METHODS: This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process. RESULTS: We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P < 0.001). EP and ER provided full treatment in 88 (34%) and 19 (12.7%) of cases, respectively (P < 0.05). The consideration rated most important was prognosis: 165 (90.2%, confidence interval: 85.0-93.7) and 121 (90.3%, confidence interval: 84.1-94.2) for EP and ER, respectively. ER rated co-morbidities and age more important than did EP (P < 0.05). Both rated discussions with family as very important. EP and ER referred 6.0% versus 11.9% patients to palliative care services, respectively. The proportion of patients taking longer than 24 h to die was higher for ER compared with that for EP (14.1% vs 4.9%, P < 0.05). CONCLUSION: We found that ER were more likely to withdraw/withhold life-sustaining healthcare, provide partial treatment, rate different considerations as important and their patients took longer to die than that of EP. Focused education and training might improve decision-making consistency between physicians and training registrars.

Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital.

OBJECTIVES: This study's objective was to determine whether tuition in medical documentation enhanced the ability of emergency medicine interns to produce effective medical records. METHODS: The study adopted a case control design, using a retrospective document audit methodology, following an education intervention during the 'More Learning for Interns in Emergency' (MoLIE) programme. It was conducted in a tertiary hospital that supports five 10 week rotations of 12 interns each year (n = 60). Controls were drawn from records written in March 2012 and cases from March 2013. A total of 250 medical records written by interns were audited, 125 from each year. RESULTS: Three categories of documentation were investigated: patient characteristics, clinical impressions and management plan using a purpose-designed score sheet. Three individual items (differential diagnosis [DDX], Support and Impressions [Impress]) showed significant improvement. The proportion of excellent scores for DDX increased by 50% from 40.8% to 61.6%. A χ(2) test for independence (with Yates continuity correction) indicated a significant association between the intervention and subsequent score (X(2) [1, n = 250] = 10.006, P < 0.001, phi -0.208). For Impress, a 48% increase in excellent scores was seen (39.2% to 58.4%). A χ(2) test for independence indicated a significant association between the intervention and subsequent score (X(2) [2, n = 250] = 11.249, P = 0.004, Cramer's V 0.212). The variable Support also improved (X(2) [2, n = 250] = 8.297, P = 0.012, Cramer's V 0.189) with the number of excellent scores increasing from 37.6% to 48.0%. CONCLUSION: The study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.

Exploration of the perceptions of emergency physicians and interns regarding the medical documentation practices of interns.

OBJECTIVES: The primary objective of the present study was to learn the factors that influence the documentation practices of ED interns. A second objective was to identify the expectations of emergency physicians (EPs) towards the medical record documentation of ED interns. METHODS: A qualitative design was adopted using semi-structured interviews in convenience samples drawn from both groups. RESULTS: Eighteen interviews were conducted with intern volunteers and 10 with EP volunteers. One (5%) intern and two (20%) EPs had received medical documentation training. Factors that encouraged interns' documentation included: patient acuity (the more critical the condition, the more comprehensive the documentation) and the support of senior colleagues. Inhibiting factors included uncertainty about how much to write, and the shift being worked (interns indicated they wrote less at night). Factors of consequence to senior personnel included the apparent reluctance of interns to document management plans. They noted that interns frequently confine their notes to assessment, investigations and treatments, whereas EPs preferred records that demonstrated intern thought processes and included such matters as future actions to follow immediate treatment. A positive theme that emerged included the high level of support interns received from their senior colleagues. Another theme, the influence of patient acuity, held both positive and negative implications for intern writing practices. CONCLUSION: The lack of formal training is an impediment to the production of useful medical records by ED interns. One solution proposed by both interns and senior personnel was the introduction of the subject into intern education programmes.

Witnessing invasive paediatric procedures, including resuscitation, in the emergency department: a parental perspective.

OBJECTIVE: To determine whether parents prefer to be present during invasive procedures performed on their children in the ED. METHODS: A prospective study using a written survey was carried out in the ED of a secondary level regional hospital in south-east Queensland. The survey conducted between August 2003 and November 2003 consisted of parental demographics, seven theoretical paediatric procedural scenarios with increasing level of procedural invasiveness (including resuscitation) and reasons for the decisions of parents to either stay with the child or leave the room. Parents of children with Australasian Triage Scale (ATS) triage category 3, 4 and 5 were surveyed. RESULTS: Of 573 surveys collected, 553 (96.5%) were completed correctly. The number of parents expressing a desire to be present during a procedure performed on their child was 519 (93.9%) for phlebotomy or i.v. cannulation of an extremity, 485 (87.7%) for nasogastric tube insertion, 461 (83.4%) for lumbar puncture, 464 (83.9%) for urinary catheter insertion, 430 (77.8%) for suprapubic bladder aspiration, 519 (93.4%) during procedural sedation and 470 (85%) during a resuscitation where the possibility existed that their child may die. The most common reason for wanting to be present was to provide comfort to their child (542/98%). The most common reason for not wanting to be present was a parental concern of getting in the way (181/33%). CONCLUSION: Most parents surveyed would want to be present when invasive procedures are performed on their children in the ED. With increasing invasiveness, parental desire to be present decreased. However, the overwhelming majority of parents would want to be in attendance during procedural sedation or resuscitation.