Palliative Care Needs of Seriously Ill,Older Adults Presenting to the Emergency Department

Objectives: The objective was to identify the palliative care needs of seriously ill, older adults in the emergency department (ED). Methods: The authors conducted a cross‐sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end‐stage liver or renal disease, stroke, oxygen‐dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face‐to‐face interviews were conducted using the Needs Near the End‐of‐Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well‐being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient–clinician relationship, and 9) overall quality of life (QOL). Results: Mean (±SD) age was 74.3 (±6.5) years and cancer was the most common diagnosis. Mean (±SD) QOL on the MQOL was 3.6 (±2.9). Over half of the patients exceeded intratest severity‐of‐needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS. Conclusions: Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs. ACADEMIC EMERGENCY MEDICINE 2010; 17:1253–1257 © 2010 by the Society for Academic Emergency Medicine     

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field

Objectives:  The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest.
Methods:  Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances.
Results:  Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role.
Conclusions:  Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.     

Pathways to Health Risk Exposure in Adult Film Performers

Despite being part of a large and legal industry in Los Angeles, little is known about adult film performers’ exposure to health risks and when and how these risks might occur. The objective was to identify exposure to physical, mental, and social health risks and the pathways to such risks among adult film performers and to determine how risks differ between different types of performers, such as men and women. Semi-structured in-depth interviews were conducted with 18 female and ten male performers as well as two key informants from the industry. Performers and key informants were recruited through Protecting Adult Welfare, adult film venues, and snowball sampling. Performers engaged in risky health behaviors that included high-risk sexual acts that are unprotected, substance abuse, and body enhancement. They are exposed to physical trauma on the film set. Many entered and left the industry with financial insecurity and suffered from mental health problems. Women were more likely than men to be exposed to health risks. Adult film performers, especially women, are exposed to health risks that accumulate over time and that are not limited to sexually transmitted diseases. At the time of the study, Grudzen was with the Robert Wood Johnson Clinical Scholars Program at the University of California, Los Angeles, Los Angeles, CA, USA; Grudzen is now with the Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, NY, USA; Ryan is with the RAND Corporation, Santa Monica, CA, USA: Margold is with Protecting Adult Welfare, Sherman Oaks, CA, USA; Torres is with the School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; Gelberg is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA     

Loss of international medical experiences: knowledge,attitudes and skills at risk

Background  

Despite the great influence International Medical Experiences (IMs) can have on young physicians and their impact on patients and communities, they are not offered in all training programs and are at risk of being reduced in some due to stringent guidelines for funding of graduate medical education.     

Care and Respect for Elders in Emergencies Program: A Preliminary Report of a Volunteer Approach to Enhance Care in the Emergency Department

Older adults who present to an emergency department (ED) generally have more‐complex medical conditions with complicated care needs and are at high risk for preventable adverse outcomes during their ED visit. The Care and Respect for Elders with Emergencies (CARE) volunteer initiative is a geriatric‐focused volunteer program developed to help prevent avoidable complications such as falls, delirium and use of restraints, and functional decline in vulnerable elders in the ED. The CARE program consists of bedside volunteer interventions ranging from conversation to various short activities designed to engage and reorient high‐risk, older, unaccompanied individuals in the ED. This article describes the development and characteristics of the CARE program, the services provided, the experiences of the elderly patients and their volunteers, and the growth of the program over time. CARE volunteers provide elders with the additional attention needed in an often chaotic, unfamiliar environment by enhancing their care, improving satisfaction, and preventing potential decline.     

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.     

Studies of Physician‐Patient Communication with Older Patients: How Often is Hearing Loss Considered? A Systematic Literature Review

Hearing loss is remarkably prevalent in the geriatric population: one‐quarter of adults aged 60–69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician‐patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician‐patient communication with older patients that were published since 2000, using the natural language phrase “older patient physician communication.” We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician‐patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one‐quarter of studies of physician‐elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.