Ceilings of treatment and treatment adequacy in the Emergency department – retropective Study
Introduction: the Emergency Department is in a constant state of antagonism due to its nature towards the acute pathology, and quality of palliative care. Our study aims to assess whether the definition of a therapeutic ceiling leads to differences in the adequacy of the diagnostic methods and therapy instituted.
Material and methods: retrospective descriptive monocentric analysis of patients who died the first 6 months of 2018 in the emergency department of Hospital do Espírito Santo de Évora.
Results: the three groups of patients were compared, one without any therapeutic ceiling defined, with the group in which they started palliative measures and the group in which the Decision to Not Resuscitate was made. There were no significant differences between ages, place of residence and comorbidities except for dementia (p=0.006), but there is a difference in the degree of dependence on activities of daily living (p<0.001). It was found that there are no differences between the number or type of complementary diagnostic tests, but there are some differences in the therapy instituted since in the group of patients in palliative care, therapy with morphine (p<0.001), butylscopolamine (p=0.001) and paracetamol (p=0.004) was more frequent. Invasive ventilation only occurred in the group of patients without therapeutic ceiling (p<0.001), while oxygen therapy was more frequent in Decision to Not Resuscitate or in palliative care groups (p<0.001).
Discussion and conclusion: the doctors of the emergency department recognize that their patients are at the end of their lives, partially adapting the therapy to control symptoms, pain and secretions.
Luz Brazão M, Nóbrega S, Gil B, Carvalho E. Atividade dos serviços de urgência hospitalares. RPMI. 2016 Jul;23(3):8-14. Disponível em: https://doi.org/10.24950/rspmi.814
Relatório Grupo Trabalho - Serviços de Urgência [Internet]. Lisboa; 2021 [citado 2021 Maio 14]. Disponível em: https://www.sns.gov.pt/wp-content/uploads/2019/11/RELATORIO-GT-Urgências.pdf.
Chan GK. End-of-life Models and Emergency Department Care. Academic Emergency Medicine. 2004;11:79-86. https://doi.org/10.1197/j.aem.2003.07.019
Machado S. Morrer num serviço de medicina interna: as últimas horas de vida. Med Interna (Bucur). 2018;25(4):286-92.
Direção-Geral da Saúde. Sistema de Vigilância: SICO/eVM - Vigilância eletrónica de mortalidade em tempo real [Internet]; 2022 [acesso 2022 Mar 10]. Disponível em: https://evm.min-saude.pt/#shiny-tab-a_local.
Shrestha TM, Aacharya RP, Neupane RP, Prajapati B. Mortality in emergency services in a university teaching hospital: a retrospective study. J Inst Med Nepal 2019;41(2):17-20. https://doi.org/10.3126/jiom.v41i2.26542.
Heymann EP, Wicky A, Carron P-N, Exadaktylos AK. Death in the emergency department: a retrospective analysis of mortality in a swiss university hospital. Emerg Med Int. 2019;2019:5263521. https://doi.org/10.1155/2019/5263521.
Kanzaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff. 2016;35(7):1303-8. https://doi.org/10.1377/hlthaff.2015.1394.
Stefanovski PH, Vladimir Radkov R, Lyubomir Ilkov T, Pencho Tonchev T, Yoana Mladenova T, Vihar Manchev K, et al. Analysis of mortality in the emergency department at a university hospital in Pleven. J Int Med Res. 2017;45(5):1553-61. https://doi.org/10.1177/0300060517707901.
Eid Mahmoud Mahfouz M. Traumatic and non-traumatic mortality in the emergency department. Int J Adv Res. 2020;8(02):1178–83. http://dx.doi.org/10.21474/IJAR01/10564.
Reignier J, Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, et al. Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine. Ann Intensive Care. 2019;9:105. http://dx.doi.org/10.1186/s13613-019-0579-7.
Forero R, McDonnell G, Gallego B, McCarthy S, Mohsin M, Shanley C, et al. A literature review on care at the end-of-life in the emergency department. Emerg Med Int. 2012; 012:486516. https://doi.org/10.1155/2012/486516.
Walzl N, Jameson J, Kinsella J, Lowe DJ. Ceilings of treatment: A qualitative study in the emergency department. BMC Emerg Med. 2019; 19(1):9. https://doi.org/10.1186/s12873-019-0225-6
Douplat M, Douplat M, Fraticelli L, Fraticelli L, Claustre C, Peiretti A, et al. Management of decision of withholding and withdrawing life-sustaining treatments in French EDs. Scand J Trauma Resusc Emerg Med. 2020;28(1):52. https://doi.org/10.1186/s13049-020-00744-7
Wordl Health Organization Palliative Care. 2020 [acesso 2021 Fev 2]. Disponível em: https://www.who.int/news-room/fact-sheets/detail/palliative-care.
Economos G, Cavalli P, Guérin T, Filbet M, Perceau-Chambard E. Quality of end-of-life care in the emergency department. Turkish J Emerg Med. 2019;19(4):141-5. https://doi.org/10.1016/j.tjem.2019.09.003.
Le Conte P, Riochet D, Batard E, Volteau C, Giraudeau B, Arnaudet I, et al. Death in emergency departments: A multicenter cross-sectional survey with analysis of withholding and withdrawing life support. Intensive Care Med. 2010;36(5):765-72. https://doi.org/10.1007/s00134-010-1800-1
ORDEM DOS MÉDICOS. Regulamento n.o 707/2016 Regulamento de Deontologia Médica. Diário da República. 2016;2.a série (139):22575-88 [acesso 2021 Fev 2]. Disponível em: http://ordemdosmedicos.pt/wp-content/uploads/2017/08/Regulamento_707_2016__Regulamento_Deontológico.pdf.
Ribera-Casado JM. Feeding and hydration in terminal stage patients. Eur Geriatr Med. 2015;6(1):87-90. https://doi.org/10.1016/j.eurger.2014.11.009.
Jox RJ, Schaider A, Marckmann G, Borasio GD. Medical futility at the end of life: The perspectives of intensive care and palliative care clinicians. J Med Ethics. 2012;38(9):540-5. http://dx.doi.org/10.1136/medethics-2011-100479.
O’Connor AE, Winch S, Lukin W, Parker M. Emergency medicine and futile care: taking the road less travelled. Emerg Med Australas. 2011;23(5):640-3. https://doi.org/10.1111/j.1742-6723.2011.01435.x.
Alves M, Abril R, Neto IG. Controlo sintomático nos doentes em fim de vida. Acta Med Port. 2017;30(1):61-8. http://dx.doi.org/10.20344/amp.7626.
Pereira A, Ferreira A, Martins J. Healthcare Received in the Last Months of Life in Portugal: A Systematic Review. Healthcare. 2019;7(4):122. https://doi.org/10.3390/healthcare7040122
Pais R, Lee P, Cross S, Gebski V, Aggarwal R. Bladder Care in Palliative Care Inpatients: A Prospective dual site cohort study. Palliat Med Reports. 2020;1(1):251-8. https://doi.org/10.1089/pmr.2020.0060
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