As a national referral center, the Emergency Department (ED) of Cipto Mangunkusumo Hospital often receives patients whom had acute exacerbation of chronic and terminal conditions, therefore, a comprehensive screening, an incorporated palliative assessment and approach for terminally ill patient should be considered to meet the appropriate resuscitation target.
This was a preliminary study done in 2017 in the effort of establishing palliative approach in Emergency Medicine. We implemented palliative screening using IPAL-EM questionnaire and early DNR decision followed by withholding strategies after initial resuscitation was appropriately delivered in the terminally ill patients.
The screening process was done by medical officers in all severity level of the ED patients. Early DNR decision was done in the resuscitation zone by an emergency physician together with a minimum of one specialist who managed the patient, followed by a written informed consent by the patient’s family.
From a total of 1348 random sample of ED patients from all triage zones, there were 659 (48.9%) patients who did not undergo palliative screening assessment by medical officers, and 689 (51.1%) patients had done the palliative screening. 104 patients resulted positive in the screening process. During June 2017 to April 2018, there were a total of 183 patients in the resuscitation zone that went through palliative care after the initial resuscitation was done. Most of them died in the emergency department (73.4%), some were sent to the ward (20%) and the rest returned home for hospice care (6.6%). Chronic conditions were found in almost all DNR patients, such as advanced cancer (45.3%), HIV-AIDS (4.9%), Autoimmune conditions (1.1%), Liver cirrhosis (4.2%), Severe COPD (1.1%), Refractory congestive heart failure (3.27%), Severe stroke (18%), and other conditions (22.13%).
Applications of palliative screening tool in our ED still needs further improvements. Palliative intervention for patients with chronic disease and critical condition should be performed early, because it can help physicians and the patient’s family to set the target of the treatment, prevent inappropriate ICU admission, and reduce futility in resuscitation. We propose further impact study to evaluate a protocol called high quality DNR Decision in ED.
palliative, resuscitation, emergency