Critical Access
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Ethical Concerns with Variation in Hospitals’ Code Status Options
Some ethicists are unaware of how code status options are named and defined at their institutions. Researchers found that at some hospitals, code status options in the electronic medical record did not even match what was in the hospital policy. Ethics should be one of the experts in this area. -
Fewer Family Meetings in ICU Are Reason for Dissatisfaction
Supporting families faced with making critical decisions for incapacitated loved ones is a core ethical duty for ICU clinicians. Yet little is known about family characteristics that predict their dissatisfaction with support during decision-making. -
Poor Agreement Between ED Patients and Physicians on Goals of Care
Ideally, goals of care discussions do not happen for the first time when the patient presents to the ED. When goals of care conversations are held earlier in a patient’s disease course, advance care planning is possible. This can alleviate the use of aggressive interventions in the event the patient decompensates or does not make a meaningful recovery.
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Evolving Efforts to Integrate Critical Care and Palliative Care
Palliative care should be integrated into serious illness care at any point following diagnosis. This can happen in conjunction with curative treatment, or as a standalone intervention focused on comfort at the end of life.
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Novel Program Decreases Transport to ED for Hospice Patients
Ventura County, CA, paramedics underwent 30 hours of training on crisis counseling, grief, and palliative care. When EMS responded to a 911 call and determined a patient was in hospice, they contacted trained staff. During a three-year study period, the percentage of hospice patients transported to the ED was 36% in the first year, 33% in the second year, and 24% in the third year. This was compared to 80% of hospice patients transported, on average, during the six months before project implementation.
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Some Code Status Discussions Are Rushed, Incomplete, or Misleading
Learning how to engage in code status conversations is as important as learning how to perform medical procedures. Clinicians would not ask patients in completely neutral terms whether they want a procedure that has no chance of working or would inflict serious harm. Any conversation around resuscitation status should take into account patients' goals and values, what is important to them in life, and the minimum acceptable quality of life.
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Policies Support Clinicians if Asked to Provide Inappropriate Care
When a family demands possibly inappropriate life-sustaining interventions, clinicians often turn to hospital policies for guidance. The authors of a recent study examined the effectiveness of Yale New Haven Hospital’s Conscientious Practice Policy. A theme emerged, focused on the inconsistent use of the policy. Whether it was used depended mostly on how resistant the family was to limiting interventions.
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Many Patients Worry About Hospital Bill During ED Visit
To prevent EMTALA problems, train staff well, giving them carefully drafted scripts to use for patients who insist on discussing insurance coverage before a medical screening exam.
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Copay Collection Cannot Delay Care, or Hospital Risks EMTALA Violation
Registrars should bring up payment or insurance only after a medical screening exam and stabilizing treatment has been provided. This means a patient should not be asked about copays or payment during the exam or while undergoing treatment.
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Palliative Care Integrated into Critical Care Settings, Including EDs
Although palliative care is integral to providing quality care, in the ED the focus tends to be on aggressive and life-saving measures. More education and training is needed to make ED providers more comfortable with integrating palliative care there.