An exploration of medical emergency team intervention at the end of life for people with advanced cancer
Introduction
Hospital-based Medical Emergency Teams (METs) were introduced to deliver rapid response and acute intervention support to improve patient outcomes (Hillman, 2010). In the acutely unwell patient, deterioration may necessitate prompt and aggressive interventions provided by a MET to prevent sub-optimal outcomes or death. In health settings where prolongation of life for patients with end stage diseases is ever more possible, it can be difficult for health care professionals to distinguish between patients for whom a MET response is warranted to correct a reversible acute event, from individuals for whom deterioration is part of the dying process (Devita and Jones, 2014, Hillman, 2010, Jones et al., 2013).
Involvement in end-of-life care is increasingly reported as a function of a MET (Hillman, 2010, Tan and Delaney, 2014). A recent systematic review found that Limitation Of Medical Treatment orders were completed more commonly during a MET response, than other intensive care interventions such as endotracheal intubation (Tan and Delaney, 2014). Evidence from a series of MET and end-of-life care studies indicates that completion rates of Not For Resuscitation or Limitation Of Medical Treatment orders in patients who receive intervention from a MET was greater than the completion rates for people who did not receive MET intervention (Chan et al., 2008, Chen et al., 2008, Downar et al., 2013, Jones et al., 2007, Jones et al., 2012, Knott et al., 2011). Specifically, METs have been shown to influence end-of-life care in 10%–33% of all hospital MET calls by guiding completion of Not For Resuscitation orders and Limitation Of Medical Treatment orders (Jones et al., 2007, Jones et al., 2012), and lead to the instigation of patient and family meetings and end-of-life discussions (Downar et al., 2013). Importantly, end-of-life discussions have been shown to result in patients receiving less aggressive treatments close to death and greater integration of palliative care interventions resulting in a better quality of life near death, as reported by caregivers (Wright et al., 2008).
In oncology settings, with the advent of novel therapies and surgical innovation, people with advanced cancer nearing the end of life can live through several episodes of clinical deterioration as a consequence of increasing tumor burden or as a side-effect of palliative or maintenance therapies. Aggressive interventions may not always be in the best interest, or the preference, of a patient as end of life nears (Hillman, 2010, Jones et al., 2013) when goals of care need to focus on reducing suffering and distress through the alleviation of symptoms (Hillman, 2010, Khan et al., 2013). Interventions consistently associated with positive quality of death include those directed at pain and symptom management. These include, completion of an advance care directive, completion of Not For Resuscitation orders and the occurrence of a family meeting (Earle et al., 2003, Glavan et al., 2008, Heyland et al., 2006). These interventions are endorsed as critical components of excellent end of life care by patients, family members and health care providers (Earle et al., 2003).
Factors identified by health care staff, patients and family members as negatively influencing quality of death include aggressive treatment, in particular Intensive Care Unit (ICU) admission, and chemotherapy administration within the last two weeks of life (Barbera and Paszat, 2006, Barbera et al., 2008, Earle et al., 2003, Miyashita et al., 2008). Diagnostic and therapeutic interventions within 48-h of death such as blood tests, X-rays and intravenous fluids, classed as life-prolonging treatments, were identified in a study of Miyashita et al. as barriers to achieving a good death (Miyashita et al., 2008).
Initiation of a MET call for patients with advanced cancer who experience clinical deterioration requires time critical decision-making by clinicians who have to consider whether escalation of care to an intensive care or high dependency unit is in the best interests of the patient. Differing opinions about the most appropriate course of action within treating teams and amongst family members, especially when there has been no prior discussion about preferences at end of life can create complex interactions where the MET team is often called upon to influence and guide resolution (Hillman, 2010).
The focus of this study was adult patients with advanced (incurable) cancer and clinical interventions received in the last week of life that have been shown to influence quality of death. The setting was a comprehensive cancer centre in Australia, with approximately 4500 admissions and 700 MET calls per year. The ICU was a small, six bed unit staffed with critical care trained nursing staff and an ICU registrar. The ICU consultant conducted twice daily reviews of patients and otherwise was on call for emergencies and discussions around patients requiring ICU admission. This study was undertaken in part fulfillment of a Master of Advanced Nursing Practice degree.
Section snippets
Aim
To explore and describe MET involvement in the care of patients admitted to a comprehensive cancer centre with advanced cancer in their last week of life.
To
Consider whether MET involvement in the care of patients with advanced cancer in their last week of life influenced quality of death.
Explore opportunities to optimise quality of death of patients dying in acute cancer settings and,
Consider the implications of the MET involvement and influence on quality of dying for cancer patients at the end
Methods
A retrospective medical case note review was undertaken to explore MET involvement in the care of patients with advanced cancer in their last week of life. Given that MET involvement in the last week of life and quality of death were the foci of interest, a prospective design was not feasible within the timeframe of the study, undertaken in part fulfillment of a Masters of Advanced Nursing Practice degree. Interventions reported to influence quality of death were recorded for two randomly
Quality of death indicators
No valid or reliable measure of quality of death, in the context of MET and cancer was found during a search of published literature in preparation for the study. As such, a comprehensive literature review was undertaken to identify interventions common to end-of-life care that could be categorised as those which have a positive influence on quality of death and those which have a negative influence on quality of death.
Medline, OVID and CINAHL databases were searched with terms, ‘end-of-life
Ethics
Ethical approval to undertake the case note review was obtained from the Low Risk Ethics Committee of the Cancer Centre. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (Project No: 13/135L).
MET and non-MET cohorts
During the three year period for data retrieval (2010–2012), 383 patients died in the Cancer Centre with 302 patients fulfilling inclusion criteria for the study. An audit of all eligible case records showed 92 patients had a MET call in the week before death (30%) (MET) and 210 did not (Non-MET) (70%). The demographic and clinical characteristics of the random samples are shown in Table 3.
There were no significant differences between the two groups in regards to demographic and clinical
Discussion
The aim of this study was to explore and describe MET involvement in the care of patients with advanced cancer in their last week of life and to consider whether MET involvement in the care of these patients influences quality of death. The impetus for the study drew on two divergent fields of evidence. The first associates MET calls with increased mortality and poorer quality of death experiences. Calzavacca et al. (2010) showed patients who experienced multiple MET calls had close to a 35%
Conclusion
Data from this study suggest that end-of-life care is a common and potentially will be an increasing aspect of MET work in a cancer settings. As such, specific training in advanced communication skills may be of benefit to multidisciplinary members of the MET who find themselves having to enter into and lead discussions regarding imminence of death, or value or futility of clinical interventions with patients, family members and other members of the health care team with whom they may have had
Conflict of interest
The authors declare that they have no conflicts of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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