Review article: Goals-of-care discussions for adult patients nearing end of life in emergency departments: A systematic review.

Goals-of-care discussions at end-of-life are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life-expectancy. It is unclear how goals-of-care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals-of-care discussions. We sought primary evidence on goals-of-care discussions in EDs with adult patients nearing end-of-life, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals-of-care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals-of-care conversations in EDs. Increased ED goals-of-care conversations increased hospice referral and reduced in-patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals-of-care' is used inconsistently across the literature. This is the first systematic review regarding goals-of-care discussions in EDs. Further research is needed on all aspects of these conversations.

Medical perspectives regarding goals-of-care consultations in Emergency Departments.

Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.

Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department.

OBJECTIVE: There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations. METHODS: This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview. RESULTS: Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min). CONCLUSIONS: Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.

Clinical variation in the use of echocardiography in Staphylococcus aureus bacteraemia: a multi-centre cohort study.

The objective of this investigation was to assess whether between-hospital variation in echocardiography usage for patients with Staphylococcus aureus bacteraemia (SAB) is explained by differences in patients' pre-test probability of endocarditis. This was a retrospective cohort study at three neighbouring hospitals in Australia. Consecutive episodes of SAB were reviewed for the presence of three endocarditis risk factors (community onset, prolonged bacteraemia and the presence of an intracardiac prosthetic device) and the performance and results of all echocardiography studies within 30 days. Multivariate logistic regression was used to examine the effect of hospital site on the performance of (i) transoesophageal and (ii) transthoracic echocardiography controlling for major endocarditis risk factors. Significant variation in echocardiography usage was demonstrated between sites in a total cohort of 1167 episodes of SAB. None of the three sites were found to exhibit echocardiography usage that could be considered consistent with current guidelines, and each differed from the guidelines in different ways. Hospital site, rather than endocarditis risk factors, was the strongest predictor of transthoracic echocardiography use; however, the use of transoesophageal echocardiography was strongly predicted by endocarditis risk factors. Variation in echocardiography use between these hospitals is not adequately explained by differences in the risk factor profile of their SAB cohorts.

Electronic health records and online medical records: an asset or a liability under current conditions?

Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information. Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital's current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary. Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution. Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services. What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events. What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement. What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).

'Why didn't you write a not-for-cardiopulmonary resuscitation order?' Unexpected death or failure of process?

Objective The aim of the present study was to understand the reasons for the delivery of non-beneficial cardiopulmonary resuscitation (CPR) attempts in a tertiary private hospital over 12 months. We determined doctors' expectations of survival after CPR for their patient, whether they had considered a not-for-resuscitation (NFR) order and the barriers to completion of NFR orders. Methods Anonymous questionnaires were sent to the doctors primarily responsible for a given patient's care in the hospital within 2 weeks of the unsuccessful CPR attempt. The data were analysed quantitatively where appropriate and qualitatively for themes for open-text responses Results Most doctors surveyed in the present study understood the poor outcome after CPR in the older person. Most doctors had an expectation that their own patient had a poor prognosis and a poor likely predicted outcome after CPR. This implied that the patient's death was neither unexpected nor likely to be reversible. Some doctors considered NFR orders, but multiple barriers to completion were cited, including the family's wishes, being time poor and diffusion or deferral of responsibility. Conclusions It is likely that futile CPR is provided contrary to policy and legal documents relating to end-of-life care, with the potential for harms relating to both patient and family, and members of resuscitation teams. The failure appears to relate to process rather than recognition of poor patient outcome. What is known about the topic? Mandatory CPR has been established in Australian hospitals on the premise that it will save lives. The outcome from in-hospital cardiac arrest has not improved despite significant training and resources. The outcome for those acutely hospitalised patients aged over 80 years has been repeatedly demonstrated to be poor with significant morbidity in the survivors. There is emerging literature on the extent of the delivery of non-beneficial treatments at the end of life, including futile CPR, the recognition of harms incurred by patients, families and members of the resuscitation teams and on the opportunity cost of the inappropriate use of resources. What does this paper add? This is the first study, to our knowledge, that has demonstrated that doctors understood the outcomes for CPR, particularly in those aged 80 years and older, and that failure to recognise poor outcome and prognosis in their own patients is not a barrier to writing NFR orders. What are the implications for practitioners? Recognition of the poor outcomes from CPR for the elderly patient for whom the doctor has a duty of care should result in a discussion with the patients, allowing an exploration of values and expectations of treatment. This would promote shared decision making, which includes the use of CPR. Facilitation of these discussions should be the focus of health service review.

Medical scribes have no impact on the patient experience of an emergency department.

OBJECTIVE: We aimed to evaluate patient perceptions of medical scribes in the ED and to test for scribe impacts on ED Net Promoter Scores, Press Ganey Surveys and other patient-centred topics. METHODS: Exploratory semi-structured interviews were conducted in the ED during wait times after scribed consultations. Interview results were used to derive topics relating to scribes. Items addressing these topics from validated surveys were combined with items from widely used patient satisfaction questionnaires. Questionnaires were administered in the ED by face-to-face approach while patients were waiting for admission/discharge or test results. Patients and doctors were blinded to the purpose of the questionnaire. The survey evaluated for non-inferiority of scribed consultations, using Net Promoter Scores, Press Ganey questions and questions specific to the presence of the scribe. RESULTS: Patient interviews did not identify any negative views regarding the presence of scribes during consultations. Thematic saturation was achieved after seven interviews. Two hundred and fifty-eight patients were approached to complete the questionnaire, and 215 participated (83%); 95 and 118 participants in the scribed and non-scribed groups, respectively. There was no difference between scribed and non-scribed consultations on the following measures of satisfaction: the Net Promoter Score, Press Ganey questions, quality of information received from doctors, communication, privacy concerns or inhibition about revealing private information and room crowding. CONCLUSION: We found no evidence that scribes reduce patient satisfaction during emergency consultations, nor prompt discomfort that might cause a patient to withhold information.

The prevalence of peripheral intravenous cannulae and pattern of use: A point prevalence in a private hospital setting.

AIMS AND OBJECTIVES: To determine the prevalence and pattern of use of peripheral intravenous cannulae in hospital wards. BACKGROUND: Peripheral intravenous cannulae are commonly used in acute health care to directly access the bloodstream for the administration of medications, intravenous fluids and blood products. Peripheral intravenous cannulae are associated with multiple adverse events including hospital-acquired bloodstream infection, thrombophlebitis and pain/discomfort. Administration of intravenous fluids is associated with impaired mobility and nocturia which may increase falls risk in the older people. DESIGN: Observational, point prevalence study. METHODS: Three private hospitals comprising a total of 1,230 beds participated in the study. Nurses recorded the presence of a peripheral intravenous cannulae, duration of insertion, state of the dressing and whether the peripheral intravenous cannulae was accessed in the previous 24 hr and for what purpose. Nurses were also asked whether they would replace the peripheral intravenous cannulae should it fail. RESULTS: Approximately one-quarter of patients had a peripheral intravenous cannulae, the majority of which had been present for <24 hr. The major use of the peripheral intravenous cannulae was antibiotic administration. Administration of intravenous fluids occurred in the presence of normal oral fluid intake. Nurses would not replace one-third of peripheral intravenous cannulae in the event of failure. A majority of patients were at increased falls risk, and one-third of these were receiving intravenous fluids. CONCLUSIONS: There is room for improvement in the utilisation of peripheral intravenous cannulae, particularly in removal and associated use of intravenous fluids. Alternative strategies for medication administration and timely switch to the oral route may reduce the risks associated with intravenous fluids. RELEVANCE TO CLINICAL PRACTICE: Vigilance is required in the use of peripheral intravenous cannulae. Consider transition of medication administration to oral intake where possible to minimise risks associated with the use of invasive devices and increased fluid intake.

Diagnosing delirium in very elderly intensive care patients.

OBJECTIVE: To determine the incidence of delirium in elderly intensive care patients and to compare incidence using two retrospective chart-based diagnostic methods and a hospital reporting measure (ICD-10). DESIGN: Retrospective study. SETTING: An ICU in a large metropolitan private hospital in Melbourne, Australia. PATIENTS: English-speaking participants (n=348) 80+ years, admitted to ICU for >24 hours. MEASUREMENTS AND MAIN RESULTS: Medical files of ICU patients admitted October 2009-October 2012 were retrospectively assessed for delirium using the Inouye chart review method, DSM-IV diagnostic criteria and ICD-10 coding data. General patient characteristics, first onset of delirium symptoms, source of delirium information, administration of delirium medication, hospital and ICU length of stay, 90 day mortality were documented. Delirium was found in 11-29% of patients, the highest incidence identified by chart review. Patients diagnosed with delirium had higher 90 day mortality, and those meeting criteria for all three methods had longer hospital and ICU length of stay. CONCLUSIONS: ICU delirium in the elderly is often under-reported and strategies are needed to improve staff education and diagnosis.

Doctors' attitudes regarding not for resuscitation orders.

Objectives The aims of the present study were to investigate doctors' attitudes regarding the discussion and writing of not for resuscitation (NFR) orders and to identify potential barriers to the completion of these orders. Methods A questionnaire-based convenience study was undertaken at a tertiary hospital. Likert scales and open-ended questions were directed to issues surrounding the discussion, timing, understanding and writing of NFR orders, including legal and personal considerations. Results Doctors thought the presence of an NFR order both should and does alter care delivered by nursing staff, particularly delivery of pain relief, nursing observations and contacting the medical emergency team. Eighty-five per cent of doctors believed they needed somebody else's consent to write an NFR order (seeking of consent is not a requirement in most Australian jurisdictions). Conclusion There are complex barriers to the writing and implementation of NFR orders, including doctors' knowledge around the need for consent when cardiopulmonary resuscitation is likely to be futile or excessively burdensome. Doctors also believed that NFR orders result in changes to goals-of-care, suggesting a confounding of NFR orders with palliative care. Furthermore, doctors are willing to write NFR orders where there is clear medical indication and the patient is imminently dying, but are otherwise reliant on patients and family to initiate discussion. What is known about the topic? Hospitalised elderly patients, in the absence of an NFR order, are known to have poor survival and outcomes following resuscitation. Further, Australian data on the prevalence of NFR forms show that only a minority of older in-patients have a written NFR order in their history. In Australian hospitals, NFR orders are completed by doctors. What does this paper add? To our knowledge, the present study is the first in Australia to qualitatively analyse doctors' reasons to writing NFR orders. The open-text nature of this questioning has been important in eliciting doctors' responses without hypothesis guessing bias. Further, we add to the literature on the breadth of considerations doctors may encounter with regard to NFR orders. What are the implications for practitioners? The findings indicate the issues impeding decision making around cardiopulmonary resuscitation relate to poor knowledge of the law, particularly around the issue of consent and confounding NFR orders with provision of palliative care. Such barriers to the completion of NFR orders expose elderly in-patients to futile and burdensome resuscitation events. The findings suggest consideration be given to education and training materials to inform doctors about jurisdictional law regarding resuscitation documentation, support decision making around cardiopulmonary resuscitation and promote goals-of-care discussions on admission.

Resuscitation orders in acute hospitals: A point prevalence study.

OBJECTIVE: To determine the prevalence of resuscitation orders and Advance Care Plans, and the relationship with Medical Emergency Team (MET) calls. METHODS: A point prevalence review of patient records at five Victorian hospital services. RESULTS: One thousand nine hundred and thirty-four patient records were reviewed, and 230 resuscitation orders and 15 Advance Care Plans found. Significantly, more resuscitation orders were found at public hospitals. Patients admitted to private hospitals were older, with shorter admissions. A further 24 orders were written following MET calls for 97 patients. Only 16% of patients aged 80+ years had a resuscitation order written within 24 hours of admission. CONCLUSION: Fewer resuscitation orders were written at admission for older adults than might be expected if goals of care and resuscitation outcome are considered. MET continue to have a prominent role in end-of-life care. Consideration and documentation about treatment plans are needed early in an admission to avoid burdensome and futile resuscitation events.

Description and student self-evaluation of a pilot integrated small group learning and simulation programme for medical students in the first clinical year.

BACKGROUND: Contemporary education for medical students should be student-centred, integrated and contextualised. Small group learning promotes clinical reasoning and skills for lifelong learning. Simulation can provide experiential learning in a safe and controlled environment. We developed a weekly integrated problem-based learning and simulation programme (IPS) over two semesters in the first clinical year to augment clinical placement experience and contextualise theory into work-relevant practice. AIM: To evaluate the new programme at Kirkpatrick level 1. METHODS: An anonymous survey of participating students. RESULTS: The programme was well liked. Students found the programme relevant and that they had a better understanding of patient safety and the assessment of the deteriorating patient. They felt it contributed to integration of theory and practice, clinical reasoning and the acquisition of non-technical skills, particularly affective and communication elements. CONCLUSION: This IPS programme in the first clinical year can deliver a student-centred curriculum to complement clinical placement that delivers the important requirements of contemporary medical student education.

Death: a foe to be conquered? Questioning the paradigm.

There are few certainties in life-death is one of them. Yet death is often thought of today as the 'loss of the battle' against illness, where in traditional societies it was the natural, meaningful, end to life. Medical knowledge and technologies have extended the possibilities of medical care and increased our life span. People living in most developed countries today can expect to survive to an advanced age and die in hospital rather than at home as in the past. Owing to these and other historical, cultural and social factors, our views on death have been skewed. Medical technology provides an arsenal of weapons to launch against death and the 'war against disease' has entrenched itself in medical philosophy. We now primarily experience death through the lens of a camera. Representations of 'death as spectacle' distort our perceptions and leave us ill-prepared for the reality. Additionally, death as a natural consequence of life has become much less visible than it was in the past due to our longer life expectancies and lack of infectious disease. The continued thrust for treatment, wedded with a failure to recognise the dying process, can rob individuals of a peaceful, dignified death. Progress being made in Advance Care Planning and palliative care is limited by the existing paradigm of death as a 'foe to be conquered'. It is time for a shift in this paradigm.

Cardiopulmonary resuscitation--time for a change in the paradigm?

Cardiopulmonary resuscitation (CPR) is the default treatment in hospital unless there is a decision to the contrary and this is documented in the patient record. The outcome of CPR in older chronically ill patients is very poor and discharge home is unlikely. Fewer not-for-resuscitation (NFR) orders are written than there are patients who would not benefit from CPR. NFR orders appear to be a marker of death, rather than the result of informed discussion about end-of-life care. There is a legal and ethical framework for the consideration of the suitability of CPR. Discussions about CPR are challenging, and uncertainty is introduced because of the lack of consensus around futility, the emotionally charged nature of the topic, misconceptions about the success of CPR and the failure to recognise that not offering CPR will allow a peaceful and supported death. Discussion around CPR can be misconstrued as a need for consent. A focus on patient and family involvement may result in an expectation that CPR is an entitlement. As part of evidence-based patient-centred care, CPR should only be offered to those for whom it is beneficial. CPR should no longer be the universal default. We propose an opt-in model, which will drive discussion and evaluation of the efficacy and suitability of CPR for the individual. A CPR discussion should occur on admission for all elderly hospital inpatients.

A guide for interprofessional case presentations.

BACKGROUND: Opportunities for interprofessional learning (IPL) and the promotion of interprofessional (IP) communication at the undergraduate level are important goals of health science faculties. IPL activities with shared curriculum validity to promote full student engagement can be challenging to identify. Case presentations that focus on patient-centred learning are one type of activity that is likely to have clinical relevance to all undergraduate groups. Guiding students and facilitators on this approach using a structured framework is necessary to maximise the desired IPL outcomes. CONTEXT: The framework was informed by two settings. Firstly, by a large metropolitan health service that provided IP clinical placements (ICPs). Six 2-week placements in aged care rehabilitation were completed by medical, nursing and allied health students Secondly, by a an inner Melbourne private hospital where weekly IP case presentations were established. INNOVATION: The innovation was a framework developed by clinical teachers and academics across two health services to guide facilitators and students participating in an IP case presentation. IMPLICATIONS: This framework, highlighting both strategies for success and potential pitfalls, may provide a guide to teachers wishing to establish student IP case presentations within their health service or clinical placement context. The deployment and use of this framework may then provide a basis to evaluate IP case-based presentations for formative or summative student assessment.

A focus group study investigating medical decision making in octogenarians of high socioeconomic status with successful outcomes following cardiac surgery.

AIM: To explore medical decision making in octogenarians having cardiac surgery. METHODS: Five focus groups conducted in a private hospital setting with octogenarians of high socioeconomic status who had successful cardiac surgery in the previous 3-13 months. RESULTS: Octogenarian's motivations for having cardiac surgery include survival, relief of symptoms, convenience and improving quality of life. The decision to have surgery involved clinical advice by doctors that the time had come to take up a surgical option. Patient's decisions did not take into account alternative treatment options either because these had not been presented by doctors or because medical management had failed. The final decision was made by patients. CONCLUSIONS: Decisions to have cardiac surgery in octogenarians are made by patients after discussions with family based on their risks as communicated by their doctors. This underlines the importance of effective risk communication by doctors to help patients make appropriate medical decisions.

A cohort study of osteoporosis health knowledge and medication use in older adults with minimal trauma fracture.

UNLABELLED: We measured osteoporosis knowledge in an older adult population with minimal trauma fracture. At follow-up, health literacy and osteoporosis knowledge had not changed significantly from baseline, and 14 (23 %) patients reported not taking any osteoporosis medication. Current osteoporosis care does not result in increased patient knowledge about their disease. INTRODUCTION: We aimed to measure health literacy and osteoporosis knowledge in an older adult population with minimal trauma fracture (MTF). METHODS: A cohort study with 3-month follow-up in Australia was conducted. Participants were hospital admissions with an MTF confirmed by X-ray. Main outcomes were the Rapid Estimate of Adult Literacy in Medicine (REALM) and Osteoporosis Knowledge Assessment Tool (OKAT) scores. Supplementary data about osteoporosis knowledge, medication use and family practitioner visits regarding osteoporosis were obtained. RESULTS: Complete data are available in 60 participants. On admission, 97 % participants had high REALM scores [mean (range) 64.7 (46.66)] and low OKAT scores [8.83 (2.16)]. At follow-up, three (5 %) participants had a further fracture. REALM and OKAT scores had not changed significantly from baseline. There was no association between OKAT score at follow-up and current treatment for osteoporosis, beliefs relating to treatment or bone health, and discussion with health care worker since discharge after adjusting for Mini Mental State Examination score. Health literacy or reading ability was not related to OKAT score. CONCLUSIONS: Osteoporosis knowledge assessed by the OKAT did not improve in the 3 months after MTF in this cohort of literate older adults, although there was some evidence of improvements in health beliefs. Current care in osteoporosis does not increase patient knowledge about their disease adequately which may impair patient effectiveness in obtaining appropriate treatment.

Sacroiliitis secondary to isotretinoin.

Reported is the case of a 17-year old male with sacroiliitis confirmed by magnetic resonance imaging (MRI) while undergoing isotretinoin treatment for acne vulgaris. The cessation of isotretinoin and symptomatic treatment resolved the symptoms within 6 weeks, with no signs of sacroiliitis on repeat MRI 10 months later. The temporal association of disease onset and commencement of isotretinoin along with rapid recovery on withdrawal supports the role of isotretinoin in this case.