Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team—a prospective multi-centre analysis

Abstract

BackgroundThe number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.MethodsIn a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows—group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care.ResultsDuring the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01).ConclusionsIn Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

Paramedics experiences and expectations concerning advance directives: A prospective, questionnaire-based, bi-centre study

“…10 Unfortunately, the reality of this situation is different in Germany; prehospital emergency medical teams are increasingly called to care for end-of-life patients. 16 A similar situation regarding advance directives could also be described for the United States. 17 There is legislation in 38 states which declares the patient's declaration of will to be binding.…”

Cancer patients, emergencies service and provision of palliative care

“…18 Knowledge and skills development for adequate pain management should be a priority for health professionals. Also, public health managers should be sensitized to this possibility in order to provide the units with standard resources for effective control of pain in 95% of cancer patients, 19,[20][21][22] and thus promote patient welliness. 7,12 There are several hypotheses for the inadequate control of pain: from difficulty of the medical staff to properly measure the complaint, to the arrogance-ignorance paradox in the medical profession; 22 in addition, there is also insufficient medical knowledge about opioids and pain treatment, and lack of pain medication or difficulty to obtain opioids, combined with the legal difficulties to prescribe such drugs.…”

“…7,12 There are several hypotheses for the inadequate control of pain: from difficulty of the medical staff to properly measure the complaint, to the arrogance-ignorance paradox in the medical profession; 22 in addition, there is also insufficient medical knowledge about opioids and pain treatment, and lack of pain medication or difficulty to obtain opioids, combined with the legal difficulties to prescribe such drugs. 12,18,20,21 A result that draws attention is that approximately half of patients do not receive any specific cancer therapy. This suggests that the emergency service allows the start of treatment for new situations resulting from the disease, or not directly related to cancer.…”

Notfallmedizinische Betreuung von Palliativpatienten am Lebensende

“…Während einer sol chen Betreuung ist mitunter ein Abwei chen von notfallmedizinischen Algorith men geboten, um den Wünschen und dem Willen der Patienten und deren be treuenden Angehörigen zu entsprechen. Solche Kenntnisse sind jedoch zurzeit in Deutschland nur in sehr seltenen Fällen Bestandteil der notfallmedizinischen Aus bildung [37,40].…”

“…Allerdings besteht auch für den Notfall mediziner sehr wohl die Verpflichtung, sich auch in der Therapie plötzlicher und vital bedrohlicher Erkrankungssituatio nen Gedanken über seine Handlungs weise, deren Sinn und die damit verbun denen Konsequenzen zu machen. Dieses gewinnt umso mehr bei der Versorgung sterbender Patienten mit lebenslimitie renden Grunderkrankungen Bedeutung [14,28,29,37,38,39,40,41].…”