Palliative Care Rounds: A Thanksgiving Break to Discuss Rib Fractures.

Rib fractures are common injuries, especially in the frail and elderly. They can happen in isolation or may be associated with significant concomitant morbidity, including but not limited to pain, pneumonia, or pneumothorax. In the palliative care population, rib fractures can be overlooked or attributed to other entities, which may lead to inappropriate treatment. The commonly accepted standards of care for the treatment of rib fractures are centered around early and adequate pain control, and stabilization of other complications. Accurate diagnosis and management demand a thorough history and physical examination, effective communication, and intentional clinical consideration of all differential diagnoses.

Emergency Palliative Care: Hospice Patients in the Emergency Department.

In this segment of the emergency department (ED) palliative care (PC) case series, we discuss a patient on hospice who presented to the ED for the management of acute symptoms and potential procedural intervention. Hospice patients frequently visit the ED and can challenge typical ED paradigms of care that often include resuscitative efforts and broad workups. Our patient had a history of advanced liver cancer, and his ED presentation was prompted by worsening abdominal pain from ascites requiring serial paracentesis. PC consultation was requested to help address the patient's symptoms and create a plan of care. The PC clinician played an important role in supporting aggressive symptom management, re-evaluating goals of care, addressing concerns about hospice, and facilitating changes in code status requested for a procedure.

Emergency Department Clinician Experience with Embedded Palliative Care.

Background: While the benefits of embedding palliative care (PC) clinicians into the emergency department (ED) are now more widely appreciated, only a handful of programs have been reported in the literature. None has previously evaluated the attitudes and experiences of the multidisciplinary ED team with such an intervention. Objectives: We evaluated the experience of ED attendings, residents, nurses, social workers, and chaplains with an embedded PC clinician in the ED. Design/Subjects: We embedded PC clinicians into an urban, academic ED in the United States and surveyed 142 ED clinicians about their experiences. We analyzed survey results using descriptive analysis for closed-ended responses and thematic analyses for open-ended responses. Measurements/Results: One hundred six of 141 clinicians responded (75% response rate). Quantitative analysis found that 99% of participants found the program valuable. Benefits of embedded PC included changing patients' management or care trajectory, freeing up ED providers for other tasks, contributing to provider education, helping providers feel more supported during their shifts, and adding to providers' skill sets and confidence in practicing primary PC. Most participants reported minimal barriers to engaging with PC. The qualitative analysis identified program approval, desire for expansion/continuation of the program, and ongoing education of ED staff. Important themes for future programs include staff education, PC proactivity, importance of adapting to the needs of the ED, and education regarding PC consultation criteria. Conclusions: ED clinicians' attitudes toward embedded PC reflected overall approval, with underlying themes of providers feeling more supported during their shifts, improved resource management, the perception of better patient care, and nursing empowerment.

The Effect of Triggered Palliative Medicine Consults on Nurse Moral Distress in the Medical Intensive Care Unit.

PURPOSE: Moral distress in the intensive care unit contributes to negative emotional experiences in nurses and adversely affects patient care. This prospective cohort study evaluates an intervention designed to improve nurse moral distress in the medical intensive care unit and assesses patient outcomes which may improve moral distress. METHODS: Nurse moral distress was measured before and after an intervention of triggered palliative consults and scheduled family meetings in the intensive care unit during the COVID-19 pandemic. Patient outcomes in the intervention medical intensive care unit were compared to a control group. RESULTS: Forty-eight nurses (n = 48/78, 62%) completed the pre-intervention survey and 33 (n = 33/78, 42%) completed the post-intervention survey. Nurse moral distress using the MMD-HP scale pre- and post-intervention (122.5 vs. 134.0, P = 0.1210) was not statistically different. Intervention group patients (n = 57/64, 89%) had earlier transition to do not resuscitate status (hazard ratio 2.1, 95% CI 1.1-4.0, P = 0.0294), higher rate of documented alternate decision makers (100% vs. 61%, P < 0.0001), and higher rate discharged to a facility (28% vs. 14%) or hospice (19% vs. 7%) (P = 0.0090). Intervention group patients with a do not resuscitate (DNR) order had lower median length of stay in the intensive care unit (4 days vs. 13 days, P = 0.0004) and hospital (10 days vs. 21 days, P = 0.0005), and lower median total hospital costs per patient ($39,067 vs. $116,476, P = 0.0029) when compared control group patients with a DNR order. CONCLUSION: Triggered palliative consults with scheduled family meetings were not associated with change in nurse moral distress. More research is needed to uncover methods to improve nurse moral distress in the intensive care unit.