Skills, expertise and role of Australian emergency clinicians in caring for people with advanced cancer.

OBJECTIVES: To explore the views of Australian emergency department (ED) clinicians about their skills, role and expertise in caring for people with advanced cancer. METHODS: A cross-sectional electronic survey of doctors and nurses working in Australian EDs was undertaken. Comparisons were made by demographics and whether respondents had received palliative care education. RESULTS: The sample comprised 444 doctors (response rate 13.5%), the majority Fellows (emergency medicine specialists) of the Australasian College for Emergency Medicine, and 237 nurses, from all states, territories and regions (metropolitan and regional). A minority (n=123, 20.6%) felt that the ED was not an appropriate place for patients with advanced cancer to present for acute care, while almost two-thirds (n=397, 64.8%) found caring for such patients rewarding, particularly nurses and those who had received palliative care education; very few (n=40, 6.5%) reported feeling uncomfortable talking to the families of dying patients. A minority (n=129, 21.0%) felt that it was not appropriate for junior medical staff to assess these patients, nurses much more than doctors (42.9% vs 8.5%, p<0.001). Over half (n=338, 55.1%) felt sufficiently skilled in managing pain for people with advanced cancer, with Fellows, more experienced doctors, and those who had received palliative care education more likely to feel skilled. CONCLUSIONS: ED clinicians in Australia, particularly those who have received palliative care education, feel comfortable and adequately skilled in managing people with advanced cancer presenting to EDs, and most find it rewarding. The importance of palliative care education to emergency clinicians' training should be recognised.

A tertiary hospital audit of the use of medical imaging in the 24 h preceding death.

This study aims to investigate the number, modality and indication for imaging studies performed on acute hospital inpatients in the 24 h prior to death. Data were obtained from retrospective analysis of deceased patients from a university affiliated tertiary hospital over a 2-year period and it was found that around one in five inpatients received medical imaging in the last 24 h of their life (364 of 1855, 19.6%).

Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians.

BACKGROUND: Patients with cancer are presenting to emergency departments (ED) for end-of-life care with increasing frequency. Little is known about this experience for patients and ED clinicians in Australia. AIMS: To assess the barriers and enablers regarding end-of-life care for cancer patients as perceived by Australian ED clinicians. METHODS: There were 4501 Australian ED clinicians invited through their professional colleges to complete an online survey, using multiple-choice and free-text responses. RESULTS: A total of 681 ED clinicians responded, most (84.2%) felt comfortable providing care to the dying and found it to be rewarding (70.9%). Although 83.8% found caring for the dying a reasonable demand on their role as clinician, 83.8% also agreed that the ED is not the right place to die. Respondents demonstrated a wide range of views regarding caring for this patient group in ED through free-text responses. In addition, 64.5% reported that futile treatment is frequently provided in the ED; the main reasons reported were that limitations of care were not clearly documented, or discussed with the patient or their family. Almost all (94.6%) agreed that advance care plans assist in caring for dying patients in the ED. CONCLUSIONS: Our findings provide important new insights into a growing area of care for ED. Barriers and enablers to optimal care of the dying patient in ED were identified, and especially the reported high occurrence of futile care, likely a result of these barriers, is detrimental to both optimal patient care and allocation of valuable healthcare resources.

Ideal care and the realities of practice: interdisciplinary relationships in the management of advanced cancer patients in Australian emergency departments.

PURPOSE: Over the course of their illness, a person with cancer is likely to see a number of different healthcare professionals, including those in the emergency department (ED). There is limited research examining the interaction and communication between the involved healthcare professionals when such a patient presents to the ED. This study aimed to explore the views and experiences of interdisciplinary interactions of healthcare professionals caring for patients with advanced cancer who present to the ED. METHODS: Focus groups and semistructured interviews were conducted with clinical staff working in ED, oncology and community and hospital-based palliative care services. Interviews and focus groups were recorded and transcribed verbatim. Thematic analysis was undertaken by three researchers independently. These themes were then discussed by the wider team and consensus reached on themes and subthemes. RESULTS: Eighty-three healthcare professionals participated in focus groups, and 11 were interviewed. The over-arching theme to emerge was one of a conflict between ideal care and the realities of practice, particularly arising where clinicians from different services were required to work together to provide care. This idea was further understood through a series of subthemes including communication, decision-making and understanding of other services. CONCLUSIONS: Participants articulated agreed upon ideals of optimal care for advanced cancer patients across all three services, however there was frequently discord between these ideals and the actual care provided. Service demands and the day-to-day stressors of practice appeared to influence people's actions and engender conflict.

Referral patterns to a palliative care service in rural Australia servicing indigenous Australians.

BACKGROUND: Territory palliative care (TPC) of the Northern Territory covers a population of 150000 over 400000 km² in urban, rural and remote settings. Thirty-two per cent of the population are indigenous Australians. There is little documentation of palliative services to the indigenous Australians. METHODS: We retrospectively reviewed the referral characteristics of patients who died in or were discharged from the TPC over 6 months in order to define unique characteristics of palliative care of such a population. RESULTS: The records of 151 consecutive patients were analysed, with a mean age 63 ± 17 years, 62% male, 59% non-indigenous, 70% urban dwellers and 71% referred for malignancies. Median time to separation was 69 days, with 33% discharged within 30 days, while 28% survived beyond 6 months. Eighty-two per cent of patients died, and of these 52% in the hospice. indigenous patients were more likely to be younger (54 vs 70 years), female (52% vs 29%), living rurally (52% vs 12%) and to die at home (47% vs 11%). CONCLUSION: These data showed major differences from the largest Australian study published so far, based on a population of predominantly non-indigenous Australians. This study identifies for the first time how TPC needs to have an encompassing service plan and delivery model to cater for indigenous patients and people in remote locations.