Aotearoa New Zealand emergency ambulance services and the provision of end-of-life care: a short survey.

AIM: To characterise emergency ambulance service (EAS) clinical roles and experiences (including cultural competency and pastoral care) in the delivery of end-of-life (EOL) and palliative care in Aotearoa New Zealand. METHOD: A nine question online survey was distributed to St John and Wellington Free Ambulance clinicians. Four questions enabled voluntary free-text comments to be submitted for thematic analysis. A further opportunity for free-text comments was available at the end of the survey. RESULTS: There were 444 participants, which is 14% of the paid ambulance workforce. 63% reported that they frequently transported EOL care patients to hospital when they could be better managed at home. EAS clinicians depend heavily on informal collegial support for pastoral care as formal debriefs are rarely offered. There were 671 free-text comments. Dominant themes included the importance of seniority, the need for further education, the importance of documented care plans and the need for better integration with community services, including hospice. CONCLUSIONS: More can and should be done to ensure EAS clinicians are supported to deliver quality EOL care for patients alongside other community providers.

Dying in hospital-staff perceptions on providing quality care.

AIM: To understand what healthcare staff perceive contributes to the quality of patient and family/whanau experiences of dying and death on a hospital inpatient ward. METHOD: A survey was created, piloted and sent to all staff members who had cared for a deceased patient within two working days of their death, at Christchurch Hospital (CH), New Zealand. The survey comprised questions evaluating whether the patients physical, emotional, social or family/whanau needs were met, using both a Likert scale and free-text options. The survey was sent over a three-month period in 2016/2017. RESULTS: A total of 169 staff responded to the deaths of 51 patients. The majority (71.3%) of staff agreed that "end-of-life care was of a high standard", with the physical symptoms domain holding the highest score for both agreement (68%) and disagreement (13%) that "physical symptoms were well managed". Qualitative analysis of free-text responses revealed three themes: coordinated care (service delivery, complex case or communication needs, teamwork); culture of practice (dignity, trust, respect and relationships); and complexity of care (encompassing complex physical symptoms or patient or family/whanau interpersonal dynamics). CONCLUSION: Evaluation of quality of death in hospitals can be enhanced by routine use of surveys of staff who cared for the deceased person. Such surveys could comprise part of a suite of tools to provide a holistic view of dying and death, complementing methods such as retrospective audits and family/whanau interviews.

Aotearoa New Zealand emergency medicine specialists on the provision of care at or near the end of life: A survey.

OBJECTIVES: The ED is an increasingly important venue for the initiation of palliative care. We sought to characterise the opinions, experience, training and education of ED staff in Aotearoa/New Zealand (NZ) with regard to specific aspects of palliative care in the NZ ED setting. METHODS: All NZ FACEMs were personally emailed a simple unstructured 16-part survey asking questions about initiating palliative care, goals of care, initiation and availability of advance care plans, frailty screening, availability of palliative expertise, training and education, cultural safety and pastoral care of staff. All EDs were contacted and a link provided for non-FACEM ED staff who wished to participate. Free-text comments were analysed for dominant themes. RESULTS: All NZ EDs had at least one participant. There was a high level of senior medical staff engagement with 60% of NZ FACEMs participating. More than 300 free-text comments from this group were available for theme analysis. A total of 93% of NZ FACEM respondents agree that palliative care should be able to be initiated in the ED. Only 25% of this group knew of training in serious illness conversations in the ED while only 34% felt culturally competent when providing end-of-life care for Maori and their whanau (family). Pastoral care for ED staff appears to be ad hoc. Time and privacy limitations were common themes. CONCLUSIONS: There is significant opportunity for quality improvement in the initiation and provision of palliative care from the ED. Attention to how departments provide pastoral care to their staff is needed.

Achievements and challenges during the development of an advance care planning program.

A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.

An evaluation of the contents of advance care plans and their use in patients admitted to a public hospital.

AIM: This retrospective review examined the influence of age and severity of comorbidities on goals-of-care in advance care plans (ACPlans) and concordance between these wishes and care received during hospital admission. METHODS: The medical records of 149 people with an ACPlan admitted to a public hospital were reviewed to evaluate concordance with treatment. The associations between age and comorbidities and goals-of-care were determined using contingency tables and logistic regression analyses. RESULTS: The majority of the review cohort were Caucasian and elderly, with people from minority ethnic groups under-represented compared to census data. Increasing age had a measurable influence on the choice of goal-of-care, whereas comorbidity severity had less influence on this decision. In 60 of the 411 hospital admissions the patient was classified as incompetent, with the goal-of-care adhered to in 59 of these cases and treatment preferences adhered to in six of seven cases. Fifty-five people had died since writing their ACPlan, with 63% dying at their preferred place or with no preference stated. CONCLUSIONS: Age and to a lesser extent the severity of comorbidities influence the choice of goal-of-care in an ACPlan. Our review also showed that end-of-life care appeared to adhere to the instructions in the plan.

Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Pain is common in patients with chronic kidney disease (CKD). Analgesics may be appropriate for some CKD patients. OBJECTIVES: To determine the prevalence of overall analgesic use and the use of different types of analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvants, and opioids in patients with CKD. DESIGN: Systematic review and meta-analysis. SETTING: Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity. PATIENTS: Adults with stage 3-5 CKD including dialysis patients and those managed conservatively without dialysis. MEASUREMENTS: Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of analgesic use, and the types of analgesics prescribed. METHODS: Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of analgesic use and the I 2 statistic was computed to measure heterogeneity. Random-effects models were used to account for variations in study design and sample populations, and a double arcsine transformation of the prevalence variables was used to accommodate potential overweighting of studies with very large or very small prevalence measurements. Sensitivity analyses were performed to determine the magnitude of publication bias and assess possible sources of heterogeneity. RESULTS: Forty studies were included in the analysis. The prevalence of overall analgesic use in the random-effects model was 50.8%. The prevalence of acetaminophen, NSAIDs, and adjuvant use was 27.5%, 17.2%, and 23.4%, respectively, while the prevalence of opioid use was 23.8%. Due to the possibility of publication bias, the actual prevalence of acetaminophen use in patients with advanced CKD may be substantially lower than this meta-analysis indicates. A trim-and-fill analysis decreased the pooled prevalence estimate of acetaminophen use to 5.4%. The prevalence rate for opioid use was highly influenced by 2 large US studies. When these were removed, the estimated prevalence decreased to 17.3%. LIMITATIONS: There was a lack of detailed information regarding the analgesic regimen (such as specific analgesics used within each class and inconsistent accounting for patients on multiple drugs and the use of over-the-counter analgesics such as acetaminophen and NSAIDs), patient characteristics, type of pain being treated, and the outcomes of treatment. Data on adjuvant use were very limited. These results, therefore, must be interpreted with caution. CONCLUSIONS: There was tremendous variability in the prescribing patterns of both nonopioid and opioid analgesics within and between countries suggesting widespread uncertainty about the optimal pharmacological approach to treating pain. Further research that incorporates robust reporting of analgesic regimens and links prescribing patterns to clinical outcomes is needed to guide optimal clinical practice.

CONTEXTE: La douleur est fréquente chez les patients atteints d'insuffisance rénale chronique (IRC). La prise d'analgésiques peut être nécessaire chez certains patients atteints d'IRC. OBJECTIFS: Établir la prévalence globale de la prise d'analgésiques chez les patients atteints d'IRC puis de la consommation des différents types d'analgésiques (acétaminophène, anti-inflammatoires non stéroïdiens [AINS], adjuvants, opioïdes). TYPE D'ÉTUDE: Revue systématique et méta-analyse. CADRE: Les études observationnelles et interventionnelles présentant des données depuis l'an 2000. Ont été exclus les cas d'insuffisance rénale aigüe et les études portant sur une population, une cause, un symptôme ou une comorbidité en particulier. SUJETS: Des adultes atteints d'IRC de stade 3 à 5, incluant des patients dialysés et des patients non dialysés pris en charge de façon conservatrice. MESURES: Le titre de l'article, le nom de l'auteur principal, le type d'étude, le pays où s'est tenue l'étude, l'année de collection des données, l'année de publication, l'âge médian des sujets, le stade de l'IRC, la prévalence de la prise d'analgésiques et les types d'analgésiques prescrits. MÉTHODOLOGIE: Les données ont été colligées dans MEDLINE, CINAHL, EMBASE et la bibliothèque Cochrane. Deux examinateurs ont trié les titres et les abrégés, évalué les articles potentiellement pertinents et extrait les données de façon indépendante. La prévalence combinée de la prise d'analgésiques a été évaluée et la statistique I 2 a été calculée pour mesurer l'hétérogénéité. Des modèles à effets aléatoires ont été employés pour tenir compte des variations entre les différents types d'études et de populations échantillonnées. Les variables de prévalence ont subi une double transformation arc-sinus pour tenir compte d'une potentielle surpondération des études comportant des mesures de prévalence très importantes ou très faibles. Des analyses de sensibilité ont été effectuées pour mesurer l'ampleur des biais de publication et évaluer de possibles sources d'hétérogénéité. RÉSULTATS: L'analyse porte sur un total de 40 études. Dans les modèles à effets aléatoires, la prévalence globale de prise d'analgésiques était de 50,8 %. Quant à la prévalence selon le type d'analgésique elle s'établissait à 27,5 % pour l'acétaminophène, à 17,2 % pour les AINS, à 23,4 % pour les adjuvants et à 23,8 % pour les opioïdes. Chez les patients atteints d'IRC de stade avancé, de possibles de biais de publication font en sorte que la prévalence réelle de l'acétaminophène pourrait s'avérer nettement inférieure à ce qu'indique cette méta-analyse. Une analyse par la méthode « trim and fill ¼ a réduit à 5,4 % la prévalence groupée estimée pour la prise d'acétaminophène. Le taux de prévalence pour la prise d'opioïdes était fortement influencé par deux vastes études américaines; en les retirant de l'analyse, la prévalence estimée passait à 17,3 %. LIMITES: Ces résultats doivent être interprétés avec prudence puisque des informations détaillées manquaient sur le schéma posologique (analgésiques particuliers utilisés dans chaque classe, comptabilisation incohérente pour les patients prenant plusieurs médicaments, prise d'analgésiques en vente libre tels que l'acétaminophène et les AINS), les caractéristiques des patients, les types de douleurs traitées et les résultats des traitements. De plus, les données sur la prise d'adjuvants étaient très limitées. CONCLUSION: Une très grande variabilité a été observée dans les profils de prescription tant pour les analgésiques opioïdes que pour les non-opioïdes. Une variabilité qui s'observe aussi tant dans un même pays qu'entre les différents pays, ce qui suggère une incertitude généralisée quant à la meilleure approche pharmacologique dans le traitement de la douleur. D'autres recherches intégrant une description rigoureuse du schéma posologique et reliant les profils de prescription aux résultats cliniques sont nécessaires pour guider l'optimisation des pratiques cliniques.

CPR in New Zealand hospitals: an alternate perspective on lawfulness and ways to improve practice.

The current approach to CPR in New Zealand hospitals is that it is attempted on all patients in cardiac arrest unless a DNR order is in place. Concern has been raised that this approach results in some "unlawful" CPR on the grounds that it is not in the patient's best interests. It has been suggested that policy change is required and one suggestion is a move away from DNR orders to mandatory "For CPR" orders. Ensuring lawfulness of CPR and more importantly quality care for patients is however more likely to be achieved not by policy change but by improved understanding by doctors and patients of the nature of these decisions, and by training programmes and work environments which value and facilitate difficult conversations, mutually respectful relationships and shared decisions.