Dying cases in emergency places: caring for the dying in emergency departments

In an ageing society, like the UK, where long-term illness dominates healthcare, there has been a change in the way that the end-of-life is approached and experienced. Advancing technology, inadequate knowledge and inconsistency in palliative care services have complicated the ability to recognise imminent dying and many people access emergency services at the end-of-life. Drawing on ethnographic research exploring end-of-life care in one large Emergency Department (ED), the authors examine the spaces of dying and death, which are created in a place designed to save life, and not necessarily to provide supportive and palliative care. Despite the high need for attention in an emergency crisis, this study shows that the approach taken to care for someone at the end-of-life, and consequently the space in which they are cared for, often falls short of the expectations of the dying patient and their relatives. It is argued that the dying body is seen as dirty and polluted in the sterile, controlled, clinical environment and is therefore 'matter out of place'. Attempts are made to conceal or remove the dying patient, the bereaved relatives and the deceased body protecting the natural order of the ED. Consequently, the individual supportive and palliative care needs of the dying are often overlooked. This paper highlights the needs of patients as death nears in the ED and argues that the critical decisions made in the ED have a significant impact on the quality of care experienced by patients, who spend the last few hours of their life there.     

Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training

ABSTRACT:  Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.     

Translating psychosocial insight into ethical discussions supportive of families in end-of-life decision-making

A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patient's family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one family's unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.     

Allow-Natural-Death (AND) Orders: Legal, Ethical, and Practical Considerations

Conversations with patients and families about the allow-natural-death (AND) order, along with the standard do-not-resuscitate (DNR) order during end-of-life (EOL) decision-making, may create engagement and understanding while promoting care that can be defended using enduring notions of autonomy, beneficence, and professional duty. Ethical, legal, and pragmatic issues surrounding EOL care decision-making seem to suggest discussion of AND orders as one strategy clinicians could consider at the individual practice level and at institutional levels. A discussion of AND orders, along with traditional DNR orders is presented. This is followed by argument and counter-argument focused on ethical, legal, and practical issues germane to EOL care decision-making associated with use of AND orders.     

Ethical challenges in the provision of end-of-life care in Norwegian nursing homes

As in other Western countries, most Norwegian nursing home patients are suffering from multi-pathological conditions and a large majority of them will die in the nursing home. End-of-life care represents many challenges, and it is a widespread concern that several nursing homes lack both resources and competence to ensure good quality care. This article examines the types and prevalence of ethical challenges in end-of-life care as nursing home staff consider them, as well as what they believe can help them to better cope with the ethical challenges. It is based on a national survey probing Norwegian nursing homes’ end-of-life care at the ward level conducted in 2007. 664 respondents from 364 nursing homes answered the questionnaire, representing 68% of the patients and 76% of the nursing home sample.     

The sensible health care professional: a care ethical perspective on the role of caregivers in emotionally turbulent practices

This article discusses the challenging context that health care professionals are confronted with, and the impact of this context on their emotional experiences. Care ethics considers emotions as a valuable source of knowledge for good care. Thinking with care ethical theory and looking through a care ethical lens at a practical case example, the authors discern reflective questions that (1) shed light on a care ethical approach toward the role of emotions in care practices, and (2) may be used by practitioners and facilitators for care ethical reflection on similar cases, in the particular and concrete context where issues around emotional experiences arise. The authors emphasize the importance of allowing emotions to exist, to acknowledge them and to not repress them, so that they can serve as a vehicle for ethical behavior in care practices. They stress the difference between acknowledging emotions and expressing them limitlessly. Formational practices and transformational research practices are being proposed to create moral space in care institutions and to support health care professionals to approach the emotionally turbulent practices they encounter in a way that contributes to good care for all those involved.     

Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review

ObjectivesTo summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities.DesignSystematic scoping review.Settings and ParticipantsPLWDs in the ED.MethodsThe following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities.ResultsFrom the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner–centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.Conclusions and ImplicationsA wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.     

Use of advance directives for nursing home residents in the emergency department

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.     

On ethical locations: the good death in Thailand, where ethics sit in places

In this article, I use ethnographic data on end-of-life care in Northern Thailand to address the relationship between ethics and place. My analysis is based on fieldwork conducted in 2007-2008, consisting of twenty in-depth oral life-histories of dying patients; ninety-five interviews with patients, family members and caretakers; fifty-four interviews with providers, administrators, civil society leaders and other key informants; as well as participant-observation of care of patients at the deathbed. In Northern Thailand, many feel that it is ethical to withdraw life support in the home, but unethical to withdraw it in the hospital. This is because the place of death is partly responsible for the quality of rebirth. Hospitals, on one hand, are powerful for saving lives; but as places to die, they are amoral, dangerous, devoid of ceremonial history and haunted by spirits. Homes, on the other hand, are optimal for dying because they are imbued with moral power from a history of beneficial ceremony and family living. Hospitalized patients at the edge of death are often rushed home by ambulance to withdraw life support in the more ethical place. I argue that the two places can be considered different ethical locations, because each is inhabited by a unique ethical framework governing withdrawal of life support. This concept has implications for the contemporary globalization of bioethics and for understanding practices that arise around ethically charged decisions.     

Checklist to meet ethical and legal obligations to critically ill patients at the end of life

Despite improvements in communication, errors in end-of-life care continue to be made. For example, healthcare professionals may take direction from the wrong substitute decision-maker, or from family members when the patient is capable; permit families to propose treatment plans; conflate values and beliefs with prior expressed wishes or fail to inquire about prior expressed wishes. Sometimes healthcare professionals know what prior expressed wishes are but do not respect them; others do not believe they have enough time to have an end-of-life discussion or lack the confidence, willingness and skills to manage one. As has been shown in initiatives to improve in surgical safety, the use of a checklist presents opportunities to potentially minimize common mistakes and errors. When engaging in end-of-life care, a checklist can help focus on what needs to be communicated rather than how it needs to be communicated. We propose a checklist to support healthcare professionals in meeting their ethical and legal obligations to patients at the end of life. The checklist should minimize common mistakes, and in situations where irreconcilable conflict is unavoidable, it will ensure that both healthcare teams and family members are informed and prepared.     

The Heart of the Matter. About Good Nursing and Telecare

Nurses and ethicists worry that the implementation of care at a distance or telecare will impoverish patient care by taking out ‘the heart’ of the clinical work. This means that telecare is feared to induce the neglect of patients, and to possibly hinder the development of a personal relation between nurse and patient. This study aims to analyse whether these worries are warranted by analysing Dutch care practices using telemonitoring in care for chronic patients in the Netherlands. How do clinical practices of nursing change when telecare devices are introduced and what this means for notions and norms of good nursing? The paper concludes that at this point the practices studied do not warrant the fear of negligence and compromised relations. Quite the contrary; in the practices studied, telecare lead to more frequent and more specialised contacts between nurses and patients. The paper concludes by reflecting on the ethical implications of these changes.     

Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

Factors Associated With Emergency Department Utilization By Urban Lesbian, Gay, And Bisexual Individuals

There are no published studies to date on emergency department (ED) utilization by the lesbian, gay, and bisexual (LGB) community despite documented lack of access to health care for this community. This study explored the frequency of ED visits and socio-demographic and health-related factors associated with ED utilization among a convenience sample of LGB individuals. A sample of 360 LGB individuals was interviewed to assess socio-demographics, sexual practices, mental health, drug use, chronic disease history, and frequency of emergency department use. Emergency department utilization was categorized as 0, 1, or ≥2 visits. Bivariate statistics were applied to assess the association of various factors with emergency department utilization. Patient characteristics were as follows: age, 29.0; male, 53.1 percent; Hispanic, 57.8 percent; Black, 37.2 percent; and reported less than a college degree, 79.4 percent. Most (77.7 percent) had a primary care doctor and (86.3 percent) were comfortable discussing LGB-related health issues with their provider. Over 12 months, 25.3 percent had 1 ED visit and 16.4 percent had ≥2 ED visits. One or more emergency department visits was significantly associated with lower age, lower education, lower income, recent psychological distress, recent mental health counseling or medications, desired mental health treatment, abuse by partner, cigarette use, marijuana use, and asthma (p < 0.05). Despite reported access to primary care, our LGB sample exhibited a higher proportion of single and ≥2 ED visits than comparable populations. Mental health and cigarette use were associated with emergency department utilization and deserve further exploration for reducing emergency department visitation by and improving emergency department care for LGB individuals.     

Use of the emergency department by Somali immigrants and refugees

Staff at a hospital emergency department (ED) located in an urban neighborhood densely populated by Somali immigrants and refugees have observed that a large number of Somali patients use the ED for care that is normally provided in a clinic setting. This article reports on the Somali population's use of the ED for such care. It also explores Somali traditions and culture in order to shed light on this population's health care practices and attitudes toward the medical system in this country, and it makes recommendations consistent with those findings for more effectively meeting the health needs of Somalis.     

Analyzing end-of-life care legislation: a social work perspective.

Several policy approaches are currently being considered in an attempt to organize a national response to the crisis surrounding quality end-of-life care. Recent healthcare efforts aimed at supporting individuals facing advanced illness are marked by debate over assisted suicide, untimely referrals to hospice care, inconsistent adherence to advance directives, and substantive amounts of unrelieved pain in end-of-life. Social workers require a clear understanding of the current political and social climate if they are to navigate the ethical dilemmas as they are presented in end-of-life care. This article discusses recently proposed policy responses to the various political and social controversies surrounding end-of-life care for individuals facing advanced illness. The analysis will suggest criteria for evaluating end-of-life policy in general and offer a framework for evaluating proposed legislation. Suggestions for making end-of-life policy more effective and areas for future research will be proposed. Finally, the implications of this policy analysis for social work will be delineated.     

Commentary on a participatory inquiry paradigm used to assess EOL simulation participant outcomes and design

Care at the end-of-life has attracted global attention, as health care workers struggle with balancing cure based care with end-of-life care, and knowing when to transition from the former to the latter. Simulation is gaining in popularity as an education strategy to facilitate health care provider decision-making by improving communication skills with patients and family members. This commentary focuses on the authors’ simulation evaluation process. When data were assessed using a participatory inquiry paradigm, the evaluation revealed far more than a formative or summative evaluation of participant knowledge and skills in this area of care. Consequently, this assessment strategy has ramifications for best practices for simulation design and evaluation.     

A Multilevel Analysis of the determinants of emergency care visits by the elderly in France

BackgroundRising numbers of visits to emergency departments (EDs), especially amongst the elderly, is a source of pressure on hospitals and on the healthcare system. This study aims to establish the determinants of ED visits in France at a territorial level with a focus on the impact of ambulatory care organisation on ED visits by older adults aged 65 years and over.MethodsWe use multilevel regressions to analyse how the organisation of healthcare provision at municipal and wider ‘department’ levels impacts ED utilisation by the elderly while controlling for the local demographic, socioeconomic and health context of the area in which patients live.ResultsED visits vary significantly by health context and economic level of municipalities. Controlling for demand-side factors, ED rates by the elderly are lower in areas where accessibility to primary care is high, measured as availability of primary care professionals, out-of-hours care and home visits in an area. Proximity (distance) and size of ED are drivers of ED use.ConclusionHigh rates of ED visits are partly linked to inadequate accessibility of health services provided in ambulatory settings. Redesigning ambulatory care at local level, in particular by improving accessibility and continuity of primary and social care services for older adults could reduce ED visits and, therefore, improve the efficient use of available healthcare resources.     

The effect of continuity of care on emergency department use

OBJECTIVE: To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population. DESIGN: A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant. SETTING: The state of Delaware. PARTICIPANTS: Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N = 11,474). INTERVENTION: None. MAIN OUTCOME MEASURES: Likelihood of making a single ED visit or multiple ED visits during the study year. RESULTS: In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76). CONCLUSIONS: This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.     

Health care social workers' views of ethical issues, practice, and policy in end-of-life care

End-of-life care decision making is perhaps the most difficult practice situation faced by health care social workers. Complex ethical issues arise from decisions regarding use of advancing medical technologies and/or other artificial treatments that may prolong life and/or compromise its quality. NASW has set forth a policy to help guide social workers dealing with end-of-life care decisions and the preservation of client self-determination in these situations. However, the present study (N = 63) revealed that a majority (57%) of social workers were not aware of the existence of, or were only somewhat familiar with the policy. Ethical dilemmas most often faced in end-of-life care situations related primarily to issues of communication between and among patients, families, and professionals. Practitioners indicated that more specific practice guidelines and increased education regarding bioethics and issues of end-of-life care are needed to be effective in assisting patients and families in end-of-life decision making.