End-of-Life Management Protocol Offered Within Emergency Room: a Multicentre Study (EMPOWER)

• Conditions: Cost Effectiveness; Palliative Care; Emergency Department
• Interventions: Other: Review of medical records; Other: Interviews, questionnaire and focused group discussions

• Registration Number: NCT03906747
• Lead Sponsor: National University Hospital, Singapore

Brief Summary

End-of-life (EOL) care has garnered increasing recognition and acceptance in the field of emergency medicine. Some emergency departments (EDs) in Singapore have instituted or plan to institute EOL care as part of the workflow. However, the EOL protocols are not standardised across all these EDs. The adherence to and quality of EOL care have not been formally measured in all institutions. Hence, gaps to improve the quality of care have yet to be determined.

The aims are to systematically measure the current quality of EOL care in three Singapore hospital EDs and identify the quality gaps; formulate interventions to address these gaps and implement the improved EOL care; and measure the improvement post-implementation. The investigators hypothesise that the current quality of EOL care in three EDs is suboptimal and the interventions planned will improve the quality of care provided.

The study team plans to conduct an interrupted time series study to detect whether the interventions have an effect significantly greater than any underlying trend over time. The quality of care indicators to be measured are timely identification of patients who require EOL care, adequacy of symptom control based on compliance to prescriptions, opportunities to discuss and develop an individualised care plan, perceived quality of care by healthcare providers and next-of-kin, and cost effectiveness. Planned interventions include refining the protocol with collaboration of content experts in palliative care, education and training of healthcare providers, and addressing specific gaps identified to improve cost effectiveness. The results of this study will form the standardisation and foundation for establishing the national benchmark for quality of EOL care in Singapore EDs.

Detailed Description

Not available

Study Timeline

• Study Start: 2019-01-18
• Study First Submitted: 2019-02-25
• Study First Submitted QC: 2019-04-05
• Study First Posted: 2019-04-08
• Primary Completion: 2021-12-31
• Status Verified: 2022-03
• Last Update Submitted: 2022-04-12
• Last Update Posted: 2022-04-13
• Study Completion: 2022-12-31

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 900

Inclusion Criteria

• Actively dying patient or high likelihood of mortality within 48 hours
• Family accepts that the goals of care are provision of comfort, symptom relief and respect of dignity
• Patient is not a candidate for cardiopulmonary resuscitation, endotracheal intubation or transfer to the intensive care unit
• Family members want to stay by patient's bedside
• Any of the life-limiting conditions such as chronic frailty with poor functional state and limited reversibility (Karnofski Performance Scale <40%), chronic severe illness with poor prognosis, or other deteriorating conditions and at risk of dying with complications that are not reversible, as subject to the treating clinician's judgment

Exclusion Criteria

• Vulnerable population e.g. prisoners, pregnant women
• Patients, relatives or staff who refused to participate
• Patients who have been recruited, or had declined participation, in the previous ED attendance(s)

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Arm && Interventions

Group	Intervention	Description
Patients	Review of medical records	Patients at their end-of-life (EOL) phase attending the emergency department
Family members and next-of-kin of (EOL) patients	Interviews, questionnaire and focused group discussions	Family members and next-of-kin of EOL patients in the emergency department
Healthcare workers	Interviews, questionnaire and focused group discussions	Comprised of doctors in the emergency department, nurses and general practitioners

Primary Outcome Measures

Name	Time	Method
Satisfaction assessed by Care of the Dying Evaluation (CODE) questionnaire	26 months	Proportion of next-of-kin who perceived that they were adequately supported (family centred)
Mortality rate within 48 hours of hospital admission	26 months	Proportion of patients who fits criteria of EOL who died within 48 hours (patient centred)
Satisfaction of healthcare workers with care rendered assessed by a staff survey	26 months	Level of satisfaction of with the overall quality of end of life care provision by doctors at ED

Secondary Outcome Measures

Name	Time	Method
Proportion of patients in EOL pathway who have documentation of an individualised care plan, and symptoms who are prescribed with appropriate medicine	26 months	Proportion of patients in EOL pathway who have documentation of an individualised care plan, and symptoms who are prescribed with appropriate medicine

Trial Locations

Locations (3)

National University Hospital; 🇸🇬 Singapore, Singapore

Khoo Teck Puat Hospital; 🇸🇬 Singapore, Singapore

Changi General Hospital; 🇸🇬 Singapore, Singapore