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.     

Effect of including cancer‐specific variables on models examining short‐term outcomes

BACKGROUND:

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) generally has not collected cancer‐specific variables. Because increasing numbers of studies are using ACS NSQIP data to study cancer surgery, the objectives of the current study were 1) to examine differences between existing ACS NSQIP variables and cancer registry variables, and 2) to determine whether the addition of cancer‐specific variables improves modeling of short‐term outcomes.

METHODS:

Data from patients in the ACS NSQIP and National Cancer Data Base (NCDB) who underwent colorectal resection for cancer were linked (2006‐2008). By using regression methods, the relative importance of cancer staging and neoadjuvant therapy variables were assessed along with their effects on morbidity, serious morbidity, and mortality.

RESULTS:

From 146 hospitals, 11,405 patients were identified who underwent surgery for colorectal cancer (colon, 85%; rectum, 15%). The NCDB metastatic cancer variable and the ACS NSQIP disseminated cancer variables agreed marginally (Cohen kappa coefficient, 0.454). For mortality, only the ACS NSQIP disseminated cancer variable and the NCDB stage IV variable were identified as important predictors; whereas the variables stage I through III, tumor (T)‐classification, and lymph node (N)‐classification were not selected. Cancer stage variables were inconsistently important for serious morbidity (stage IV, T‐classification), superficial surgical site infection (N‐classification), venous thromboembolism (metastatic cancer), and pneumonia (T‐classification). With respect to neoadjuvant therapy, ACS NSQIP and NCDB variables agreed moderately (kappa, 0.570) and predicted superficial surgical site infection, serious morbidity, and organ space surgical site infection. The model fit was similar regardless of the inclusion of stage and neoadjuvant therapy variables.

CONCLUSIONS:

Although advanced disease stage and neoadjuvant therapy variables were predictors of short‐term outcomes, their inclusion did not improve the models. Cancer 2013. © 2012 American Cancer Society.     

Developing quality indicators for cancer end‐of‐life care

Quality indicators applicable to cancer end‐of‐life care exist, but have not been widely implemented. To advance this field, the authors worked with the Agency for Health Care Research and Quality and the National Cancer Institute to organize a national symposium to discuss key issues and future goals, based on a conceptual framework. Discussions focused on 8 key domains in end‐of‐life cancer care: pain; dyspnea; communication, care planning, and decision making; psychosocial care; communication about chemotherapy; depression; continuity, coordination, and care transitions; and spirituality and closure. Key themes included the need for clarity on definitions and key aspects of care within domains, the need to start implementing indicators in more developed domains, and the importance of high‐quality symptom assessment and documentation of key processes. Key areas for future work include development of more outcome indicators, methods to better incorporate indicators and patient‐reported outcomes into clinical processes of care, and coordination across domains and settings. Measuring the quality of end‐of‐life cancer care is essential to understanding how best to improve patient outcomes and care. Cancer 2009. © 2009 American Cancer Society.     

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