Philip G Richardson1, Jaimi Greenslade1, Jonathon Isoardi2, Michael Davey3, Mark Gillett4, Alicia Tucker5, Sharon Klim6, Anne-Maree Kelly6, Ibrahim Abdelmahmoud1. 1. Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia. 2. Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia. 3. Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia. 4. Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia. 5. Emergency Department, Royal Hobart Hospital, Hobart, Tasmania, Australia. 6. Joseph Epstein Centre for Emergency Department Research, Western Health, Melbourne, Victoria, Australia.
Abstract
OBJECTIVE: We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER). METHODS: This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process. RESULTS: We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P < 0.001). EP and ER provided full treatment in 88 (34%) and 19 (12.7%) of cases, respectively (P < 0.05). The consideration rated most important was prognosis: 165 (90.2%, confidence interval: 85.0-93.7) and 121 (90.3%, confidence interval: 84.1-94.2) for EP and ER, respectively. ER rated co-morbidities and age more important than did EP (P < 0.05). Both rated discussions with family as very important. EP and ER referred 6.0% versus 11.9% patients to palliative care services, respectively. The proportion of patients taking longer than 24 h to die was higher for ER compared with that for EP (14.1% vs 4.9%, P < 0.05). CONCLUSION: We found that ER were more likely to withdraw/withhold life-sustaining healthcare, provide partial treatment, rate different considerations as important and their patients took longer to die than that of EP. Focused education and training might improve decision-making consistency between physicians and training registrars.
OBJECTIVE: We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER). METHODS: This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process. RESULTS: We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P < 0.001). EP and ER provided full treatment in 88 (34%) and 19 (12.7%) of cases, respectively (P < 0.05). The consideration rated most important was prognosis: 165 (90.2%, confidence interval: 85.0-93.7) and 121 (90.3%, confidence interval: 84.1-94.2) for EP and ER, respectively. ER rated co-morbidities and age more important than did EP (P < 0.05). Both rated discussions with family as very important. EP and ER referred 6.0% versus 11.9% patients to palliative care services, respectively. The proportion of patients taking longer than 24 h to die was higher for ER compared with that for EP (14.1% vs 4.9%, P < 0.05). CONCLUSION: We found that ER were more likely to withdraw/withhold life-sustaining healthcare, provide partial treatment, rate different considerations as important and their patients took longer to die than that of EP. Focused education and training might improve decision-making consistency between physicians and training registrars.
Authors: Nita Khandelwal; Ann C Long; Robert Y Lee; Cara L McDermott; Ruth A Engelberg; J Randall Curtis Journal: Lancet Respir Med Date: 2019-05-20 Impact factor: 30.700