CARTAS AO EDITOR / LETTERS TO EDITOR

 

Emergency Medicine and Palliative Care: The Need for a Joint Agenda

A Emergência Médica e a Medicina Paliativa: A Necessidade de uma Agenda Comum

 

Bernardo Pereira^1,2
https://orcid.org/0000-0001-9259-4288

Paulo Reis-Pina^3-5
https://orcid.org/0000-0002-4665-585X

¹Intensive Care Unit, Dr. José de Almeida’s Hospital, Cascais, Portugal.

²National Institute of Medical Emergency, Medical Emergency and Resuscitation Vehicle, Helicopter Emergency Medical Service, Portugal.

³Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal.

⁴School of Medicine, University of Minho, Portugal.

⁵Faculty of Medicine, University of Lisbon, Portugal.

 

Abstract:

Emergency medicine´s scope of action carries an inherent risk of inadequate care for patients in need for palliative care. The relevance of this theme requires a deep reflection as well as its mandatory inclusion in the agenda of the different medical training societies.

Keywords: Emergency Medicine; Medical Staff, Hospital /education; Palliative Care; Patient Care Planning; Intensive Care Units.

 

Resumo:

O campo de acção da emergência médica acarreta um risco inerente de inadequação de cuidados aos doentes com necessidades paliativas. A relevância do tema impõe uma reflexão assertiva que visa, em última instância, a sua inclusão mandatória  na  agenda  dos  diferentes  órgãos  de  formação médica.

Palavras-chave: Corpo Clínico Hospitalar/educação; Cuidados Paliativos; Medicina de Emergência; Planeamento da Assistência ao Doente; Unidades de Cuidados Intensivos.

 

Emergency Medicine´s (EM) scope of practice carries an inherent  risk  of  inadequate  care  for  patients  with  palliative needs.

Resorting to EM services can occur anytime during the advanced stage of a chronic and progressive disease. This may occur, on the one hand, due to the scarcity of alternatives in medical assistance for outpatients, perhaps due to the failure to recognize organ dysfunctions as terminal events; on the other hand, because EM services can truly be adequate in certain situations. Although the dimension of the problem requires quantification, its inadequacy is extremely harmful, if it occurs.

EM has a well-defined focus of action that should not be distorted. Conditioned automatisms and invasive interventions, supported by a curative mentality, as well as decision-making that takes place in a limited time and is based on limited clinical information, are an antithesis of the functioning of Palliative Medicine. And if ethical principles are of equal value,¹ what about the justice inherent in the inappropriate use of EM? It is therefore urgent to return the emergency to EM.²

It is imperative to keep in mind that a patient with palliative needs is not necessarily a patient in an agonal state and that Palliative Medicine covers multiple pathologies with different survival rates. Do not patients in need for palliative care have the right to benefit from EM? Can not the resolution of an urgent situation be beneficial and constitute the best course of action to that person? And what about the fact that Medicine is not Cartesian - science and art must coexist in medical practice - prognosis is often not clear³; consequently, the decision about the therapeutic aggressiveness can be extremely difficult in some settings.

Breaking down the critical patient chain of survival, from pre-hospital care to post-resuscitation care, there are several aspects to consider when considering improvement projects.

Having in mind proportionality principles, even before the activation of EM teams, there should be an anticipation of the problems, as well as a well-defined, individualized plan of care incorporating whenever possible end-of-life directives.

In the pre-hospital setting, it is essential to promote a suitable and adequate triage system for patients in need for palliative care by implementing communication channels with national networks of continuous care. Also, investments should be made in the training of differentiated professionals, capable of making clinical decisions or knowing how to adequately postpone them, free of an algorithmic and protocolized medicine. Only by investing in the training of health professionals is it possible to create a common ground and tailored care to the right patient, in the right way, at the right time.

In the hospital environment, it is important to promote multi and interdisciplinarity, as well as the inclusion of the patient and caregivers in the care plan. It is necessary to recognize uncertainty and give the benefit of the doubt through therapeutic trials,^4,5 always having the patient at the center of the decisions, avoiding dysthanasia, exulting orthothanasia as a component of the medical scope.

In an era characterized by a growing crisis in fundamental values, facing a fragmented, individualized, and defensive Medicine, it is important to remember that our duty, as healthcare professionals, is to be at service for our patients. EM and Palliative Medicine, despite having vastly different scopes of action, share a common ground. The same dilemmas occur because the same fundamental value is the core of every practice: “Life”. It is therefore crucial to raise awareness to this potential inadequacy of end-of-life care so that the different specialty boards, and medical societies can join forces and create task forces dedicated to this theme.

 

REFERÊNCIAS

1.      Gracia D. Moral deliberation: the role of methodologies in clinical ethics. Med Health Care Philos. 2001;4:223-32.         [ Links ]

2.      Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al. ICU  admission,  discharge,  and  triage  guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. Crit  Care  Med.  2016;44:1553-602. doi: 10.1097CCM.0000000000001856.         [ Links ]

3.      Thiery G, Azoulay E, Darmon M, Ciroldi M, De Miranda S, Levy V, et al. Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study. J Clin Oncol. 2005;23:4406-13. doi: 10.1200/JCO.2005.01.487.         [ Links ]

4.      Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1:5. doi: 10.1186/2110-5820-1-5.         [ Links ]

5.      Shrime MG, Ferket BS, Scott DJ, Lee J, Barragan-Bradford D, Pollard T, et al. Time-limited trials of intensive care for critically ill patients with cancer: how long is long enough? JAMA Oncol. 2016;2:76-83. doi: 10.1001/jamaoncol.2015.3336.         [ Links ]

 

Responsabilidades Éticas

Conflitos de Interesse: Os autores declaram a inexistência de conflitos de interesse na realização do presente trabalho.

Fontes de Financiamento: Não existiram fontes externas de financiamento para a realização deste artigo.

Proveniência e Revisão por Pares: Não comissionado; revisão externa por pares.

 

Ethical Disclosures

Conflicts of interest: The authors have no conflicts of interest to declare.

Financing Support: This work has not received any contribution, grant or scholarship.

Provenance  and  Peer  Review:  Not  commissioned;  externally  peer  reviewed.

 

© Autor (es) (ou seu (s) empregador (es)) e Revista SPMI 2020. Reutiliza- ção permitida de acordo com CC BY-NC. Nenhuma reutilização comercial.

© Author(s) (or their employer(s)) and SPMI Journal 2020. Re-use permitted under CC BY-NC. No commercial re-use.

 

Correspondence / Correspondência:

Paulo Reis Pina – paulopina@medicina.ulisboa.pt

Internista, Casa de Saúde da Idanha, Sintra, Portugal

Casa de Saúde da Idanha, Rua Bento Menni, nº 8, 2605-077, Belas

 

Received / Recebido: 02/07/2020

Accepted / Aceite: 06/07/2020

 

Publicado /Published: 28 de Setembro de 2020