A Practical Framework for Serious Illness Communication Developed in a Mistrust Pressure Cooker: Lessons from a COVID Intensive Care Unit in Brazil (FR204B)

Outcomes: 1. Explore a serious illness communication model grounded in establishing trust for patient populations in whom mistrust abounds 2. Discuss best practices for applying this communication framework to diverse patient populations with whom you work. During the early days of the COVID-19 pandemic, the world looked on as Brazil experienced one of the first peak waves, caring for patients when prognosis was uncertain, and infrastructure and capacity were severely insufficient. Through this lived experience of developing and running a COVID intensive care unit at a public hospital with extensive barriers to trust, we realized that many existing serious illness communication models do not account for such settings of high baseline mistrust. Grounded in literature on the basic human need of establishing trust as well as the lived experience of running a COVID intensive care unit during such unprecedented circumstances, we developed a framework for serious illness communication in settings of high mistrust. This presentation will highlight the four main components of this communication model: Establishing Trust, Tuning Emotions, Emotional Synchrony, and Cognitive Alignment. The presentation will also include case examples of how utilizing this model changed communication patterns and decision making. We will also share data surrounding patient outcomes. We will also discuss the need for more diverse communication models, both in the United States and globally to meet diverse patient needs. Particularly in healthcare settings where mistrust abounds, it is crucial for clinicians to explore patients' goals and values with cultural humility and with an emphasis on proving themselves trustworthy. Lastly, we will engage in audience discussion, applying this communication model developed in one Latin American country during a humanitarian crisis more broadly to fit the needs of a diverse patient population across multiple settings. Sharing lessons learned from our experiences developing a culturally tailored, practical, trust-enhancing serious illness communication model is one step toward dismantling our healthcare systems' inherent biases and engaging in co-creation of diverse communication models.

Palliative care in the emergency department: A qualitative study exploring barriers, facilitators, desired clinician qualities, and future directions.

OBJECTIVE: To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED-PC, and clinicians' perspectives on the future of ED-PC. METHOD: This qualitative study using semi-structured interviews was conducted in June-August 2020. Interviews were analyzed via a two-phase Rapid Analysis. The study's primary outcomes (innovations in ED-PC during COVID) are published elsewhere. In this secondary analysis, we examine interviewee responses to broader questions about ED-PC currently and in the future. RESULTS: PC providers perceived as successful in their work in the ED were described as autonomous, competent, flexible, fast, and fluent in ED language and culture. Barriers to ED-PC integration included the ED environment, lack of access to PC providers at all times, the ED perception of PC, and the lack of a supporting financial model. Facilitators to ED-PC integration included proactive identification of patients who would benefit from PC, ED-focused PC education and tools, PC presence in the ED, and data supporting ED-PC. Increased primary PC education for ED staff, increased automation, and innovative ED-PC models were seen as areas for future growth. SIGNIFICANCE OF RESULTS: Our findings provide useful information for PC programs considering expanding their ED presence, particularly as this is the first study to our knowledge that examines traits of successful PC providers in the ED environment. Our findings also suggest that, despite growth in the arena of ED-PC, barriers and facilitators remain similar to those identified previously. Future research is needed to evaluate the impact that ED-PC initiatives may have on patient and system outcomes, to identify a financial model to maintain ED-PC integration, and to examine whether perceptions of successful providers align with objective measures of the same.

Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic.

CONTEXT: Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. OBJECTIVES: To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. METHODS: For this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations. RESULTS: Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories. CONCLUSION: Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.

The Experience of Emergency Department Providers With Embedded Palliative Care During COVID.

CONTEXT: Although the importance of palliative care (PC) integration in the emergency department (ED) has long been recognized, few formalized programs have been reported, and none have evaluated the experience of ED clinicians with embedded PC. OBJECTIVES: We evaluate the experience of ED clinicians with embedded PC in the ED during the coronavirus disease pandemic. METHODS: ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis. RESULTS: There were 134 ED clinicians surveyed. About 101 replied (75% response rate). Of those who had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult because of ED volume (5%). About 98% of respondents felt that having PC in the ED was either valuable or very valuable. Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high-quality goal-concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED. CONCLUSION: ED clinicians' perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.