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Three Part Question

[For Emergency Medicine doctors] would [an educational intervention in palliative care] [be useful.]

Clinical Scenario

You are taking some time after your CT3 year to learn some extra skills that would be useful to your job as an EM consultant. One of the jobs you felt would be useful is palliative care. Intuitively, you feel that uncontrolled pain is an emergency we often see and personally you feel there is much for you to learn in the appropriate management and subsequent referral pathway of palliative care patients. You feel pain management is one of our biggest roles, in common with end of life care specialists. You have no evidence base to show to others how Emergency medicine doctors feel about their knowledge in palliative care and if an Educational intervention would lead to increased knowledge of and confidence in this area and hence a better patient experience.

Search Strategy

Embase 1974 to 2014 October 08, Ovid MEDLINE(R) 1946 to October Week 1 2014, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations October 08, 2014
Search strategy: Emergency medicine and palliative care and education).af.

107 Advanced. 7 limit 6 to english language 99

Search Outcome

99 articles found of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lamba S, Mosenthal A., Rella J., et al 2012 May USA	All EM residents and faculty of one academic facility . 45 participants.	Retrospective questionnaire	Ninety-three percent (42/45) of eligible participants completed the survey (28 residents, 14 faculty). Respondents agreed/strongly agreed that palliative care skills are an important competence for EM (88%, 37/42) and that they would	EM residents reported minimal training in pain management (46%, 13/28), managing hospice patients (54%, 15/28), withdrawal/withholding life support (54%, 15/28), and managing the imminently dying (43%, 12/28).	retrospective rather than a prospective RCT because of the nature of the research question. 45 is a fairly small sample size for the question we are trying to answer. It is based in the US rather than the UK hence the results may not be as relevant to UK practise. However, the topic is very relevant to my question as to if an educational intervention in palliative care would be useful
Meo N, Hwang U, Morrison R.S. 01 May 2011. USA	Survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City.228 Residents	Descriptive questionnaire based study	Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a	New York City emergency medicine doctors reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care.	This is Not a randomised controlled trial. There are reasonable numbers in the study (228 residents). It is Very relevant to my question as to whether palliative care skills training would be important to ED doctors.
Shearer F.M., Rogers I.R., Monterosso L et al June 2014 Australia	All medical and nursing staff working in a private ED in Perth, Western Australia, were asked to complete a combined quantitative and qualitative survey. (Returned by 22 doctors and 44 nurses)	quantitative and qualitative survey (Retrospective Questionnaire based study)	Surveys were returned by 22 doctors and 44 nurses, with most reporting only working knowledge of palliative care but clinical proficiency in symptom control. Confidence in palliative care provision was lower among nursing than medical staff but educational needs were similar.	Our study suggests that although ED staff expressed confidence regarding symptom management in palliative care, they lacked understanding of the patients in whom a palliative approach could be applied and sought further education in areas, such as end-of-life communication and ethical issues. ED specific training and clinical interventions in palliative care provision would seem to be needed and justified.	Not a randomised controlled trial or a prospective study. Fairly small sample numbers. Relevant study to my PICO question.Based in Australia rather than the UK
Quest T., Emanuel L., Gisondi M., et al. February 2010. USA	The Education in Palliative and End-of-Life Care for Emergency Medicine (EPEC-EM) Project is a train-the-trainer program designed to teach emergency clinicians core palliative medicine knowledge and skills needed in the emergency setting. 100 participants, 43 responses	Questionnaire based study	Of the 100 participants who attended one of three conferences, 43 responded; 77% were emergency physicians and 88% reported teaching during their clinical practice. Of those respondents who had disseminated the course locally, 46% reported teaching 2-5 hours of content; 11% taught 6 - 10 hours; 19% taught 10-15 hours; and 16% taught > 15 hours. Conference modules considered essential to daily clinical practice included: Communication and Goals; Breaking Bad News; Chronic Pain; Withdrawing and Withholding Care; and Malignant Pain.	Trainers that have completed the EPEC-EM train-the-trainer conference are generally emergency medicine educators and report a substantial perceived impact on their knowledge and skills. Trainers actively disseminate the curriculum. Implications for Research, Policy, or Practice: Further efforts to reach emergency practitioners with the curriculum have the potential to impact education of emergency providers.	Questionnaire based study rather than a randomised controlled trial. Response rate of only 43% hence it is possible there is selection bias in these results.Again, based in the US rather than the UK so not as relevant to my study in the UK.

Comment(s)

Palliative care education has been shown to be of significant demand in the US and the skills learnt would appear to be relevant to a significant minority of patients presenting in the emergency department. Improved training of the doctors working in the Emergency department so that they know the basic principles of palliative management and when and how to contact palliative care specialists for further advice is very important. It is possible that many emergency medicine doctors in the UK do not know the name of the local hospice or how to contact them. Unfortunately, there are no relevant studies that have been performed in the UK and it is not known if these skills would be equally useful in the UK environment.

Clinical Bottom Line

Extrapolating US data, it appears that an educational intervention in palliative care would indeed significantly improve the ED doctors management of end of life scenarios. We do not yet have any UK based studies in this area and this is an important area for new research and subsequently relevant intervention.

References

1. Lamba S, Mosenthal A., Rella J., et al Emergency medicine resident education in palliative care: a needs assessment. Journal of Palliative medicine 2012 May;15(5):516-20. doi: 10.1089/jpm.2011.0457.
2. Meo N, Hwang U, Morrison R.S. Resident perceptions of palliative care training in the emergency department. Journal of Palliative Medicine. 14 (5) (pp 548-555), 2011. Date of Publication: 01 May 2011. [Journa
3. Shearer F.M., Rogers I.R., Monterosso L et al Understanding emergency department staff needs and perceptions in the provision of palliative care EMA - Emergency Medicine Australasia. 26 (3) (pp 249-255), 2014. Date of Publication: June 2014.
4. Quest T., Emanuel L., Gisondi M., et al. Impact of the education in palliative and end-of-life care project on emergency medicine education and practice. Journal of Pain and Symptom Management. Conference Boston, MA United States. 39 (2) (pp 334-335), 2010. Date of Publication: February 2010.