Authors (including presenting author) :
Chan KI(1), Wong OF(1), Ko S(1), Wong CH (1), Chan WK(1), Chan SL(1), Yip LF(1)
Affiliation :
(1) Accident and Emergency Department, North Lantau Hospital
Introduction :
With rapid growing of the elderlies in Hong Kong, it is common for the elderlies present to the Accident and Emergency Department (AED) at the End-of-Life (EOL) stage. The EOL care aims to promote comfort and preserve dignity of dying patients by providing holistic care. Although the importance of EOL care is well recognized, it remains challenging to promote EOL services under the fast-paced environment at AEDs, as the dominant focus and resources are always diverted to patients with reversible conditions.
Despite numerous barriers, North Lantau Hospital (NLTH) AED advocate a unique EOL care service model since 2017. This model advocates a paradigm shift by entrusting Emergency Medicine (EM) physicians to initiate comprehensive palliative care discussions, departing from the traditional reliance on palliative care specialists. Diverging from conventional practices that predominantly cater to imminent dying patients, our approach focuses in the early identification of terminally-ill patients and fostering open dialogues with families to establish personalized "Goals of care”.
Objectives :
- To foster a shared decision-making process involving patients and their families
- To formulate individualized caring plan to enhance the quality of care of terminal illness
- To avoid patient transportation to other hospitals
- To transcend suffering through holistic support such as symptomatic control, spiritual and social support
- To optimize comfort care through multidisciplinary care
Methodology :
The EOL care service is initiated by EM physicians. The inclusion criteria encompassing patients with terminal malignancy, post-cardiac arrest with profound hypoxic brain injury, irreversible or terminally-ill condition that life-sustaining treatment is deemed to be futile.
Upon recruitment, the EM specialist discusses the willingness of life-sustaining treatment with the patient and/or family, covering interventions such as intubation or inotropic support etc. Symptomatic control is addressed by the use of medication such as opioids. The responsible nurse assesses the needs of the patient and/or family, subsequently making referrals to various parties. The nurse formulates individualized care plans, encompassing symptom assessment, relief measures, and allocation of the designated environment.
Following the passing of a patient, aftercare program is activated to provide crucial psychological and spiritual support for the bereaved family. Sympathy cards are delivered to provide heartfelt messages and condolences.
Result & Outcome :
With the inception of the EOL care program in 2017, a total of 245 patients were recruited, with an average age of 84, range 52 to 105. The patient spectrum encompassed conditions such as post-cardiac arrest, terminal carcinoma and unsalvageable intracranial hemorrhage (ICH) etc.
All patients were admitted to the EMW after the "Goal of care" was discussed with patients and/or their families. The program delivered multidisciplinary care including the engagement of physiotherapists and occupational therapists for limb mobilization or splinting, speech therapist and dietitian for tailored nutritional support for patients. Special events to accomplish patients’ last wishes such as birthday party, baptism and wedding ceremony had been facilitated. The individual's desires were embraced, created meaningful experiences for both the patient and their loved ones during this profound stage of life.
In the early stages of implementation, the program was evaluated by questionnaires completed by patient’s families. The response rate is limited due to the self-paced nature of questionnaire completion. 74 questionnaires were collected, revealing high satisfaction among patients' families, particularly in areas such as symptomatic control (n=57), facility support (n=66), and spiritual assistance (n=69). Identified areas for improvement including standardized opioid protocols and ongoing training for healthcare workers, were addressed through subsequent follow-ups.
