Palliative care in emergency services: an integrative review

Abstract

This article seeks to understand the approach of emergency teams to patients with an advanced chronic condition from a palliative care perspective. This integrative review searched for articles in five databases using the descriptors “emergency medical services,” “patient assistance team,” “attitudes of health personnel” and “palliative care”. At first, 12,290 publications were identified, which were then reduced to 26 articles for the final sample. Among the main measures found in the literature to use palliative care in emergency services, the following stand out: individualized and flexible care plan; network management; access to the palliative care team; empathic communication; identification eligible patients; and control of symptoms. We thus conclude that emergency teams must recognize the importance of palliative care and redirect the care focused in “saving lives” towards a care that preserves human dignity.

Patient care team; Emergency service, hospital; Palliative care

Resumo

O objetivo do artigo é conhecer a abordagem de equipes de emergência à assistência de pacientes com doença crônica avançada, na perspectiva dos cuidados paliativos. O texto traz resultados de revisão integrativa que buscou artigos em cinco bases de dados, utilizando os descritores “serviços médicos de emergência”, “equipe de assistência ao paciente”, “atitude do pessoal de saúde” e “cuidados paliativos”. Inicialmente, foram identificadas 12.290 publicações, reduzidas, após análise, a uma amostra final de 26 artigos. Entre as principais medidas mencionadas na literatura para levar os cuidados paliativos à emergência, estão: plano de cuidados individualizado e flexível; gestão de redes; acesso à equipe de cuidados paliativos; comunicação empática; identificação dos pacientes elegíveis; e controle de sintomas. Conclui-se que as equipes de emergência precisam reconhecer a importância dos cuidados paliativos nesse serviço, redirecionando o cuidado concentrado em “salvar vidas” para um cuidado que preserve a dignidade humana.

Equipe de assistência ao paciente; Serviço hospitalar de emergência; Cuidados paliativos

Resumen

Este artículo tuvo como objetivo comprender el enfoque del equipo de emergencia a los pacientes con enfermedad crónica avanzada desde una perspectiva paliativa. Se realizó una revisión integradora, buscando artículos en portugués, inglés y español en las bases de datos MEDLINE, LILACS, SciELO, IBECS y CINAHL, utilizando los descriptores “servicios médicos de emergencia”, “equipo de asistencia al paciente”, “actitud del personal de salud” y “cuidados paliativos”, con 12.290 publicaciones identificadas inicialmente, que tras su análisis dieron como resultado una muestra final de 26 artículos. Entre los principales aspectos destacan: plan de cuidados individualizado y flexible; gestión de redes; acceso al equipo de cuidados paliativos; comunicación empática; identificación de pacientes elegibles; y control de síntomas. Se concluye que el equipo de emergencias necesita reconocer la importancia de los cuidados paliativos en este servicio y reorientar los cuidados enfocados a “salvar vidas” hacia cuidados que “preserven la dignidad humana”.

Grupo de atención al paciente; Servicio de urgencia en hospital; Cuidados paliativos

Life expectancy has increased worldwide due to advances in the health area, reduced mortality and expanded access to health services. However, the issue of quality of life has been widely discussed, since, along with life expectancy, the prevalence of chronic-degenerative diseases, such as cancer, Alzheimer and multiple sclerosis, has also increased ¹.

Faced with this scenario of chronic illness, we observe weakness in primary care, which has led users to resort to the emergency department care as an easier means of access, available 24 hours, seven days a week ¹. In these environments, it is common to care for patients with pain, dyspnea and vomiting who, without effective outpatient or home care, see the emergency care as the only and immediate option ¹-². These patients expect resolute, compassionate and individualized care. However, when it comes to patients in end-of-life care, studies ¹-³ point out a certain distancing by the professional team.

Patients turn to the emergency department mainly due to the lack of availability of a palliative care team. However, the emergency team recognizes that it cannot apply the same criteria used at the outpatient clinic level when attending these patients. The argument is that the accelerated dynamics of the service does not allow professionals to dedicate more time to be with the patient and family and develop a closer interaction ³.

Although not the ideal place to start palliative care, the emergency department could integrate the management of symptoms in acute crises, deconstructing a culture of care only for acute cases, to enable care focused on the patient, and not exclusively on the disease. This already occurs in some developed countries, such as the United States, where the project Improving Palliative Care in Emergency Medicine was created, an embryonic education movement for emergency teams that defines objectives to evaluate the patient, including end-of-life care and symptom management ¹.

Considering this context, this study seeks to understand, through a literature review and from the perspective of palliative care, the emergency teams’ approach to patients with advanced chronic disease.

Method

This article presents results of an integrative review developed in six stages: definition of the object and research question, search in the literature, categorization, evaluation, interpretation, and synthesis of knowledge ⁴. To elaborate the research question, the PICO strategy was used: patients in palliative care (patient), emergency team approach (intervention) and emergency care (outcome). The third element (comparison) was not used.

Articles published between June 2013 and June 2018 were included, based on selection by convenience. The search took place between July and August 2019 on the following databases: Medical Literature Analysis and Retrieval System Online (Medline/PubMed); Latin American and Caribbean Literature in Health Sciences (Lilacs); Scientific Electronic Library Online (SciELO); Índice Bibliográfico Español en Ciencias de la Salud (Ibecs), and Cumulative Index to Nursing and Allied Health Literature (Cinahl). The following descriptors were used in Portuguese, English and Spanish, extracted from the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH): “emergency medical services,” “patient care team”, “attitude of health personnel” and “palliative care.”

Texts in English, Portuguese or Spanish that addressed palliative care in the emergency department were included. Theses, dissertations, essays, duplicate articles, (integrative or systematic) reviews, book chapters and editorials were excluded. The search on the databases resulted in 12,290 publications, which comprised the global scenario (Figure 1). After applying the inclusion and exclusion criteria, as well as careful analysis based on the objective of the study, carried out by two independent researchers, the result was a sample of 26 articles read in full (Chart 1).

Figure 1
Flowchart of the study selection process

Ethical principles were observed, with due mention to the authors included. The results were analyzed in a descriptive manner, from the synthesis of the emergency teams’ approach to patients in palliative care and comparisons between the studies included.

Results

The publications included in the sample have different approaches, covering both the perspective of patients and family members and that of the health team and service administrators. Most studies were published in 2014 (26.9%, n = 7). The remaining years, 2013, 2015, 2016, 2017 and 2018, had five, three, five, four and two articles published, respectively. The qualitative approach was the most used, present in 20 articles. The other six were quantitative studies. The countries with the largest number of publications were the United States (38.4%, n = 10) and Australia (30.8%, n = 8). Four studies were from the United Kingdom (15.4%), and the remaining four were conducted one in each country: Spain, France, Thailand and Turkey. Publications in English predominated, with only one study being published in Spanish. Table 1 presents the main information regarding the publications.

Table 1
Main studies that comprised the integrative review

Base, journal, year, country	Objective	Team approach
Medline, J Palliat Med, 2013, USA 3	Discover barriers perceived by doctors when providing palliative care in the emergency department.	– Identification of eligible patients. – Access to the palliative care team.
Medline, West J Emerg Med, 2013, USA 5	Describe the approach and the role of the emergency team regarding palliative and end-of-life care.	– Identification of eligible patients. – Access to the palliative care team. – Care network management. – Interdisciplinary team performance. – Emergency team professional as a reference in palliative care. – Individualized and flexible care plan. – Differentiation between palliative care and end-of-life care.
Cinahl, J Palliat Med, 2013, USA 6	Evaluate whether interconsultations with palliative care teams initiated in the emergency department reduce the inpatient length of stay, compared to interconsultations initiated after hospital admission.	– Identification of eligible patients. – Access to the palliative care team. – Care network management. – Interdisciplinary team performance.
Cinahl, Ann Emerg Med, 2013, USA 7	Identify administrative factors that interfere with the availability and provision of palliative care in the emergency department	– Care network management. – Individualized and flexible care plan. – Support to the family.
Cinahl, Am J Hosp Palliat Care, 2013, Ireland 8	Identify palliative care patients assisted in the emergency department	– Identification of eligible patients. – Access to the palliative care team. – Empathic communication.
Medline, J Palliat Med, 2014, USA 9	Evaluate the effectiveness of a multimodal intervention strategy to improve end-of-life care in the emergency department.	– Empathic communication. – Control of symptoms. – Differentiation between palliative care and end-of-life care. – Minimization of futile treatments. – Adoption of advance directives (living will). – Individualized and flexible care plan.
Medline, Asian Pac J Cancer Prev, 2014, Turkey 10	Identify characteristics of patients with cancer diagnosis admitted to the emergency department.	– Control of symptoms. – Care network management. – Integration with home care.
Medline, Support Care Cancer, 2014, Australia 11	Explore views and experiences of interdisciplinary interaction of health professionals who care for patients with advanced cancer attended in the emergency department.	– Empathic communication. – Individualized and flexible care plan. – Care network management. – Integration with home care. – Interdisciplinary team performance.
Medline, Emerg Med Australas, 2014, Australia 12	Investigate the perspectives and needs of an emergency team in relation to palliative care.	– Control of symptoms. – Empathic communication. – Individualized and flexible care plan.
Medline, Intern Med J, 2014, Australia 13	Evaluate barriers and enablers in relation to end-of-life care for cancer patients attended in the emergency department.	– Individualized and flexible care plan. – Minimization of futile treatments. – Adoption of advance directives (living will).
Medline, J Palliat Med, 2014, USA 14	Identify the rate of interconsultation with the palliative care team in the emergency department for patients with advanced dementia.	– Identification of eligible patients. – Access to the palliative care team.
Medline, Acad Emerg Med, 2014, USA 15	Evaluate the early referral of patients with advanced cancer from the emergency department to the palliative care unit.	– Identification of eligible patients. – Access to the palliative care team.
Medline, Palliat Med, 2015, Australia 16	Explore the understanding of palliative care by health professionals who care for patients with advanced cancer in an emergency department.	– Control of symptoms. – Identification of eligible patients. – Empathic communication. – Discussion about ethical dilemmas.
Medline, Int J Intern Emerg Med, 2015, Australia 17	Discuss the attitudes of emergency physicians regarding the care for patients with advanced cancer, thinking about how their attitudes affect access to the palliative care service.	– Identification of eligible patients. – Access to the palliative care team. – Care network management.
Medline, Emerg Med Australas, 2015, Australia 18	Investigate the experiences and attitudes of the emergency team of a public hospital when approaching palliative care.	– Control of symptoms. – Support to the family. – Empathic communication. – Adoption of advance directives (living will).
Medline, Ann Emerg Med, 2016, France 19	Explore physicians’ perceptions and attitudes when making decisions about the transfer of critically ill elderly patients from the emergency department to the ICU.	– Identification of eligible patients. – Empathic communication. – Adoption of advance directives (living will). – Discussion about ethical dilemmas.
Medline, Int Nurs Rev, 2016, Thailand 20	Describe the meaning of experiences lived by nurses when caring for critically ill patients in the emergency department.	– Individualized and flexible care plan. – Minimization of futile treatments. – Empathic communication. – Support to the family. – Support in the family’s mourning process. – Psychological and spiritual care.
Medline, J Emerg Nurs, 2016, Spain 21	Describe the experiences of physicians and nurses in relation to the loss of dignity of a person in end-of-life care attended in an emergency department.	– Control of symptoms. – Care network management. – Individualized and flexible care plan. – Minimization of futile treatments. – Adoption of advance directives (living will). – Support to the family. – Support to the team. – Preservation of the patient’s dignity.
Medline, J Emerg Nurs, 2016, USA 22	Implement a best practice model to care for dying patients.	– Identification of eligible patients. – Access to the palliative care team. – Presence of the specialist nurse. – Detailed discussion among the interdisciplinary team.
Medline, BMJ Open, 2016, England 23	Understand the decision-making process of people with advanced cancer and their caregivers when seeking emergency care.	– Interdisciplinary team performance. – Control of symptoms.
Cinahl, J Pain Symptom Manage, 2017, England 24	Explore physicians’ attitudes towards intubation of terminally ill cancer patients.	– Access to the palliative care team. – Individualized and flexible care plan. – Minimization of futile treatments.
Medline, BMJ Support Palliat Care, 2017, Australia 25	Explore the perspective of emergency physicians on their skills, role and experience in caring for people with advanced cancer.	– Control of symptoms. – Care network management.
Medline, Am J Hosp Palliat Care, 2017, England 26	Explore the reasons why patients in need of palliative care go to the emergency department.	– Control of symptoms. – Care network management.
Medline, Age Ageing, 2017, England, Ireland and USA 27	Identify barriers and enablers for the empowerment of older people with advanced disease and the impact of palliative care.	– Specialized team. – Empathic communication. – Individualized and flexible care plan. – Access to the palliative care team.
Medline, Palliat Med, 2018, Australia 28	Explore experiences and perceptions of patients with advanced cancer and caregivers who seek emergency services.	– Control of symptoms. – Empathic communication. – Care network management. – Individualized and flexible care plan.
Medline, Support Care Cancer, 2018, England 29	Explore opinions and experiences of emergency department patients subsequently hospitalized.	– Control of symptoms. – Empathic communication. – Care network management. – Individualized and flexible care plan.

Discussion

The analysis on how emergency teams assist patients in palliative care allowed us to answer the research question and identify specificities or points of intersection. The most evident aspects were: care based on an individualized and flexible plan, management of the care network, and access to palliative care teams ³,⁶-⁸,¹⁰-¹⁵,¹⁷,²⁰-²¹,²⁴-²⁹.

The need for individualized and flexible care is justified by the profile of the patients, who often arrive with a diagnosis of chronic and advanced disease, with a history, in general, of incongruous assistance, marked by invasive methods, overuse of technologies and ignored suffering or, worse, increased by dysthanasia practices ¹⁴.

Early referral to the interconsultation team can reduce both waiting time ¹⁵ and hospital stay. One of the studies identified that a group of patients with access to the interconsultation team in the emergency department had their length of stay reduced by 3.6 days, compared to another group that only went through interconsultation after hospital admission ⁶.

The resistance in initiating the palliative approach in the emergency department may be related to the professionals’ attitudes and beliefs regarding the illness process, as well as to a mistaken understanding of the emergency department as a sector of accelerated dynamics, in which there would be no time for interaction between team, patient and family. Thus, patients with advanced chronic diseases, such as people with dementia and cancer, are not seen as individuals who experience active suffering, caused by acute events and who need clinical stability and an individualized and flexible care plan to return to their basal condition ⁶,¹⁴.

It is worth mentioning that these patients seek the emergency department for several reasons: anxiety about acute crises; lack of prior guidance in the primary care network; feelings of safety and familiarity with the hospital environment, and, in many situations, difficulty in accessing primary care, especially in urgent cases or at times when these services are not delivered ²³.

Studies ⁶,¹⁴,²⁴ point out that the justifications of emergency professionals for not carrying out the interconsultation are based on empirical definitions about the pertinence of the conduct and the availability to start a dialogue with the family. However, it is noteworthy that the participation of the family and especially of the patient in care decisions is a right that should be ensured by professionals. Guiding and clarifying the questions of users and family members make them participants in care. Although the family does not decide on technical issues, it participates in decision-making ³⁰.

As an active and multidisciplinary approach, palliative care breaks paradigms, defending a new model centered on the patient’s autonomy, and not on the team or the disease, in favor of quality of life and results aimed at comfort and human dignity ²². However, a research carried out in an Australian hospital points out a persistent reluctance in including such care in the emergency department, despite discussions already underway on the need to revise systems to include palliative care ²⁵.

Palliative care in the emergency department is marked by difficulties in communication, in the recognition of empathy as a fundamental aspect and in the identification of eligible patients ¹-³,⁸-¹³,¹⁵-¹⁶,¹⁸-²⁰,²⁷-²⁹. Although they recognize the need for palliative care in the emergency department, professionals do not feel prepared to deliver them, especially regarding communication skills, the ability to address issues related to the end of life and the knowledge to identify and refer to interconsultation patients who need this care ¹².

A research carried out in Thailand sought to describe the experience of nurses when caring for critically ill patients in an emergency department. The results point to the need to qualify these professionals. Nurses state that the time the patient remains in the emergency department is very short, and therefore palliative care is not prioritized. Sedation and medications used to relieve pain are never prescribed. Such care would take time and would conflict with the recommendation to transfer patients as quickly as possible to other units, or to release them to return to their homes ²⁰.

However, practical measures, with good results, could be undertaken, such as providing a place with privacy for the patient and family to fully live the singular moment of death, and recognizing the advance directives (manifested by living will or lasting power of attorney) as an instrument that contemplates the patient’s will in relation to treatments. It would also be important, during health professionals’ training, to develop communication skills and ways to deal with bad news ²⁰,²¹.

A research with Spanish nurses and emergency physicians who had specialized training shows that these professionals feel more comfortable in dealing with terminally ill patients ²¹. On the other hand, the lack of a culture of palliative care, awareness, empathic communication and professional training makes this approach difficult ²¹.

It is important to clarify that the communication about palliative care in the emergency department cannot follow the same criteria used in the traditional model of inpatient units ³,⁷. Among the strategies that can also work in the emergency department, the following can be mentioned: distinguish palliative care from end-of-life palliative care; develop the initial approach with a team of physicians and nurses; recognize advance directives; perfect team formation, and have a professional who exercises leadership, sensitizing colleagues and showing how to overcome barriers ⁵. Whenever possible, the patients and their families should also be included in the decision-making process, just as chaplains, psychologists and social workers must participate in care ²².

The last synthesis points to control of symptoms. This point is important, since patients describe their experiences in care as a time of anxiety and uncertainty associated with the long wait before the management of symptoms ²⁷. The most reported physical symptoms were: pain, dyspnea, nausea, vomiting, and constipation ⁸,¹⁰,²⁶. However, there are also emotional and social issues: anxiety related to the progress of the disease; recurrent search for emergency department care in the face of acute crises; feelings of safety and familiarity with the hospital environment; and difficulties in accessing primary care services ²³.

A study carried out in Ireland shows that up to 94% of people who arrive at the emergency department with the aforementioned symptoms remain under observation for an average time of nine hours. However, 51.5% of these patients would not need to seek an emergency department if the management of home care was active and resolute⁸. Another study, developed in England, shows that 83% of the services require emergency care in the face of an acute crisis, and that the needs of the people served are not met by primary or home care. Thus, the emergency department plays a fundamental role in managing acute crises and must be recognized as a gateway to the health network ²⁶.

Excellence in care involves recognizing the patient’s needs at the moment of acute crisis, which requires the team to have empathetic communication skills and identify the objectives inherent to care and control of symptoms ⁹. In this sense, one must be cautious about recommending that the patient should seek the primary, outpatient or home care network, given that the worsening of chronic conditions is constant and not always resolved in environments other than the emergency department. Thus, professionals who claim that patients in palliative care do not need emergency care and should be seen only in the primary or outpatient care network are mistaken ²⁶.

The competence of professionals in the management of symptoms has also been identified as a strong point of palliative care in the emergency department ⁹,¹⁸,²²,²³,²⁵. One study pointed out that 84.2% of physicians felt comfortable in caring for patients with advanced disease ¹³. In another research, 64.8% of nurses found it rewarding to attend to this patient profile. The nurse has been appointed as the team’s link in the provision of care, interconnecting with the patient and their family, optimizing comfort care and ensuring a dignified and humane environment ²².

Final considerations

The research showed that emergency departments are usually seen as spaces only for quick actions, which brings obstacles to patient comfort and the preservation of dignity, precisely in a space theoretically designed to save lives. Thus, many professionals still do not recognize the emergency department as a place where one can offer palliative care. As main measures that could reverse this scenario, it is worth highlighting: individualized and flexible care plan, management of care networks, access to the palliative care team, empathic communication, identification of eligible patients, and control of symptoms.

Many patients and family members go to the emergency department looking for safety. Thus, the emergency team has to recognize the importance of palliative care, redirecting care focused on “saving lives” to a care that preserves human dignity, recognizing death as part of the life cycle.

Among the limitations of this study, we highlight the use of only five databases, not including Web of Science and Embase, and the absence of national studies. Despite these limitations, we expect the article to be an opportunity for reflection, especially for emergency professionals, encouraging them to know the philosophical principles of palliative care. The objective is that these principles guide their performance even in accelerated dynamics such as that of emergency departments, providing resolutive end-of-life care to patients and families, with compassion, comfort, and dignity.

Referências

• ¹
  Mierendorf SM, Gidvani V. Palliative care in the emergency department. Perm J [Internet]. 2014 [acesso 10 jan 2019];18(2):77-85. DOI: 10.7812/TPP/13-103
• ²
  Bailey C, Murphy R, Porock D. Trajectories of end-of-life care in the emergency department. Ann Emerg Med [Internet]. 2011 [acesso 10 jan 2019];57(4):362-9. DOI: 10.1016/j.annemergmed.2010.10.010
• ³
  Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med [Internet]. 2013 [acesso 10 jan 2019];16(2):143-7. DOI: 10.1089/jpm.2012.0402
• ⁴
  Hopia H, Latvala E, Liimatainen L. Reviewing the methodology of an integrative review. Scand J Caring Sci [Internet]. 2016 [acesso 10 jan 2019];30(4):662-9. DOI: 10.1111/scs.12327
• ⁵
  Rosenberg M, Rosenberg L. Integrated model of palliative care in the emergency department. West J Emerg Med [Internet]. 2013 [acesso 10 jan 2019];14(6):633-6. DOI: 10.5811/westjem.2013.5.14674
• ⁶
  Wu FM, Newman JM, Lasher A, Brody AA. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med [Internet]. 2013 [acesso 10 jan 2019];16(11):1362-7. DOI: 10.1089/jpm.2012.0352
• ⁷
  Grudzen CR, Richardson LD, Major-Monfried H, Kandarian B, Ortiz JM, Morrison RS. Hospital administrators’ views on barriers and opportunities to delivering palliative care in the emergency department. Ann Emerg Med [Internet]. 2013 [acesso 10 jan 2019];61(6):654-60. DOI: 10.1016/j.annemergmed.2012.06.008
• ⁸
  Wallace EM, Cooney MC, Walsh J, Conroy M, Twomey F. Why do palliative care patients present to the emergency department? Avoidable or unavoidable? Am J Hosp Palliat Care [Internet]. 2013 [acesso 10 jan 2019];30(3):253-6. DOI: 10.1177/1049909112447285
• ⁹
  Bailey FA, Williams BR, Woodby LL, Goode PS, Redden DT, Houston TK et al. Intervention to improve care at life’s end in inpatient settings: the BEACON trial. J Gen Intern Med [Internet]. 2014 [acesso 10 jan 2019];29(6):836-43. DOI: 10.1007/s11606-013-2724-6
• ¹⁰
  Yildirim B, Tanriverdi O. Evaluation of cancer patients admitted to the emergency department within one month before death in Turkey: what are the problems needing attention? Asian Pac J Cancer Prev [Internet]. 2014 [acesso 10 jan 2019];15(1):349-53. DOI: 10.7314/apjcp.2014.15.1.349
• ¹¹
  Lane H, Weil J, Jelinek GA, Boughey M, Marck CH, Weiland TJ et al. Ideal care and the realities of practice: interdisciplinary relationships in the management of advanced cancer patients in Australian emergency departments. Support Care Cancer [Internet]. 2014 [acesso 10 jan 2019];22(4):1029-35. Disponível: https://bit.ly/3tnLfJ6
  » https://bit.ly/3tnLfJ6
• ¹²
  Shearer FM, Rogers IR, Monterosso L, Ross-Adjie G, Rogers JR. Understanding emergency department staff needs and perceptions in the provision of palliative care. Emerg Med Australas [Internet]. 2014 [acesso 10 jan 2019];26(3):249-55. DOI: 10.1111/1742-6723.12215
• ¹³
  Marck CH, Weil J, Lane H, Weiland TJ, Philip J, Boughey M, Jelinek GA. Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians. Intern Med [Internet]. 2014 [acesso 10 jan 2019];44(4):362-8. DOI: 10.1111/imj.12379
• ¹⁴
  Ouchi K, Wu M, Medairos R, Grudzen CR, Balsells H, Marcus D et al. Initiating palliative care consults for advanced dementia patients in the emergency department. J Palliat Med [Internet]. 2014 [acesso 10 jan 2019];17(3):346-50. DOI: 10.1089/jpm.2013.0285
• ¹⁵
  Kistler EA, Sean MR, Richardson LD, Ortiz JM, Grudzen CR. Emergency department-triggered palliative care in advanced cancer: proof of concept. Acad Emerg Med [Internet]. 2015 [acesso 10 jan 2019];22(2):237-9. DOI: 10.1111/acem.12573
• ¹⁶
  Weil J, Weiland TJ, Lane H, Jelinek GA, Boughey M, Marck CH et al. What’s in a name? A qualitative exploration of what is understood by “palliative care” in the emergency department. Palliat Med [Internet]. 2015 [acesso 10 jan 2019];29(4):293-301. DOI: 10.1177/0269216314560801
• ¹⁷
  Weiland TJ, Lane H, Jelinek GA, Marck CH, Weil J, Boughey M, Philip J. Managing the advanced cancer patient in the Australian emergency department environment: findings from a national survey of emergency department clinicians. Int J Intern Emerg Med [Internet]. 2015 [acesso 10 jan 2019];8. DOI: 10.1186/s12245-015-0061-8
• ¹⁸
  Russ A, Mountain D, Rogers IR, Shearer F, Monterosso L, Ross-Adjie G, Rogers JR. Staff perceptions of palliative care in a public Australian, metropolitan emergency department. Emerg Med Australas [Internet]. 2015 [acesso 10 jan 2019];27(4):287-94. DOI: 10.1111/1742-6723.12428
• ¹⁹
  Fassier T, Valour E, Colin C, Danet F. Who am I to decide whether this person is to die today? Physicians’ life-or-death decisions for elderly critically ill patients at the emergency department-ICU interface: a qualitative study. Ann Emerg Med. [Internet]. 2016 [acesso 10 jan 2019];68(1):28-39. DOI: 10.1016/ j.annemergmed.2015.09.030
• ²⁰
  Kongsuwan W, Matchim Y, Nilmanat K, Locsin RC, Tanioka T et al. Lived experience of caring for dying patients in emergency room. Int Nurs Rev [Internet]. 2016 [acesso 10 jan 2019]; 63(1): 132-8. DOI: 10.1111/inr.12234
• ²¹
  Granero-Molina J, Díaz-Cortés MDM, Hernández-Padilla JM, García-Caro MP, Fernández-Sola C. Loss of dignity in end-of-life care in the emergency department: a phenomenological study with health professionals. J Emerg Nurs [Internet]. 2016 [acesso 10 jan 2019];42(3):233-9. DOI: 10.1016/ j.jen.2015.10.020
  » https://doi.org/10.1016/ j.jen.2015.10.020
• ²²
  Rojas E, Schultz R, Linsalata HH, Sumberg D, Christensen M, Robinson C, Rosenberg M. Implementation of a life-sustaining management and alternative protocol for actively dying patients in the emergency department. J Emerg Nurs [Internet]. 2016 [acesso 10 jan 2019];42(3):201-6. DOI: 10.1016/ j.jen.2015.11.006
  » https://doi.org/10.1016/ j.jen.2015.11.006
• ²³
  Henson LA, Higginson IJ, Daveson BA, Ellis-Smith C, Koffman J, Morgan M, Gao W. ‘I’ll be in a safe place’: a qualitative study of the decisions taken by people with advanced cancer to seek emergency department care. BMJ Open [Internet]. 2016 [acesso 10 jan 2019];6(11). DOI: 10.1136/bmjopen-2016-012134
• ²⁴
  Kim, Kenneth; Chakravarthy, Bharath; Anderson, Craig; Liao, Solomon. To intubate or not to intubate: emergency medicine physicians’ perspective on intubating critically III, terminal cancer patients. J Pain Symptom Manage [Internet]. 2017 [acesso 10 jan 2019];54(5):654-60. DOI: 10.1016/ j.jpainsymman.2017.07.038
  » https://doi.org/10.1016/ j.jpainsymman.2017.07.038
• ²⁵
  Jelinek GA, Marck CH, Weil J, Lane H, Philip J, Boughey M, Weiland TJ. Skills, expertise and role of Australian emergency clinicians in caring for people with advanced cancer. BMJ Support Palliat Care [Internet]. 2017 [acesso 10 jan 2019];7(1):81-7. DOI: 10.1016/j.jpainsymman
• ²⁶
  Green E, Ward S, Brierley W, Riley B, Sattar H, Harris T. “They shouldn’t be coming to the ED, should they?”: a descriptive service evaluation of why patients with palliative care needs present to the emergency department. Am J Hosp Palliat Care [Internet]. 2017 [acesso 10 jan 2019];34(10):984-90. DOI: 10.1177/1049909116676774
• ²⁷
  Selman LE, Daveson BA, Smith M, Johnston B, Ryan K, Morrison RS et al. How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a cross-national ethnography in England, Ireland and the USA. Age Ageing [Internet]. 2017 [acesso 10 jan 2019];46(2):300-9. DOI: 10.1093/ageing/afw193
• ²⁸
  Philip J, Remedios C, Breen S, Weiland T, Willenberg L, Boughey M et al. The experiences of patients with advanced cancer and caregivers presenting to emergency departments: a qualitative study. Palliat Med [Internet]. 2018 [acesso 10 jan 2019];32(2):439-46. DOI: 10.1177/0269216317735724
• ²⁹
  Chen H, Johnson M, Boland E, Seymour J, Macleod U. Emergency admissions and subsequent inpatient care through an emergency oncology service at a tertiary cancer centre: service users’ experiences and views. Support Care Cancer [Internet]. 2018 [acesso 10 jan 2019];27:451-60. DOI: 10.1007/s00520-018-4328-5
• ³⁰
  Cogo SB, Lunardi VL, Quintana AM, Girardon-Perlini NMO, Silveira RS. Assistência ao doente terminal: vantagens na aplicabilidade das diretivas antecipadas de vontade no contexto hospitalar. Rev Gaúcha Enferm [Internet]. 2017 [acesso 10 jan 2019];38(4). DOI: 10.1590/1983-1447.2017.04.65617

Publication Dates

• Publication in this collection
  6 Sept 2021
• Date of issue
  Apr-Jun 2021

History

• Received
  8 Jan 2020
• Reviewed
  20 Apr 2021
• Accepted
  22 Apr 2021