Edited by George Jelinek
OUTLINE
21.1 Death and dying 695
21.2 Sexual assault 698
21.3 Family violence 704
21.4 Alcohol-related illness 708
21.5 The challenging patient 717
21.6 End of life decision making and palliative care 727
21.7 Organ and tissue donation 731
21.1 Death and dying
William Lukin and Bryan G Walpole
Essentials
1 Death and management of the dying process is core business for emergency medicine.
2 Death in the emergency department can either be sudden and unexpected or the natural and expected evolution of a disease process.
3 Emergency physicians have a responsibility to understand the principles of a good death and to manage departmental deaths in alignment with these principles.
4 Communication skills for discussing death and dying are part of the skill set of an emergency physician.
5 How a death is managed in the emergency department has a profound impact on the grieving process of the next of kin. Emergency physicians should understand and be able to manage their role in establishing a normal grieving process for bereaved families.
6 Organ donation services should be offered unless there are clinical contraindications.
7 Local statutory obligations for coronial reporting must be well understood and observed.
8 Emotional health of emergency medicine practitioners should be monitored and external assistance sought when appropriate.
Introduction
For most people, the normal expectations are that they will live a full life, that parents will pre-decease their children and that the dying person will be able to deal with any unfinished business and die surrounded by loved ones, as portrayed in the media. There is an expectation that death will be natural, peaceful and, for the majority, pain free. In marked contrast to such expectations is the unexpected death of a loved one at an emergency department (ED) where sudden unexpected and violent death is not uncommon.
Death and dying patients are an inevitable part of emergency medicine practice. In 2011/12, 1956 people died in emergency departments in Australia and a further 5477 were pronounced dead on arrival [1]. These deaths can be either be sudden and unexpected or the natural evolution of a dying process. Sudden unexpected death from trauma or rapid overwhelming disease processes is somewhat unique to emergency medicine and management of patients and families in this situation is something with which all emergency physicians must be familiar. The management of the patient dying from a life-limiting illness in the emergency department needs a different skillset to unexpected death but is just as important. For some, facing a surviving family or counselling a dying patient may symbolize failure in the battle against disease; however, it is a privilege and, done correctly, can be an extremely fulfilling part of emergency medicine practice. In emergency medicine, one does not have the benefit of a long-standing doctor–patient relationship. The support and mutual understanding that are the cornerstones of family practice are missing and so rapport must be forged in the heat of the moment. Families need space and time to come to grips with death, but both are limited in the ED. Access block and overcrowding should not preclude sensitive, empathetic grief management.
To follow the strain and pace of a difficult resuscitation with the grace and emotional energy required to care for a family requires considerable effort. Emergency physicians also have a duty of care to the survivors who deserve compassion as much as the recently deceased.
Similarly, management of the patient dying from a life-limiting illness can be a complex and challenging task. Patients and their families in this setting attend emergency departments for many reasons including fear, unrelieved symptomatology and the inability to access appropriate services. This is not always a failure of the system; sometimes an emergency department is the only place that can deliver the care they require. ED clinicians should have sufficient knowledge of local processes to enable advocacy roles for these patients with special needs and foster partnerships with local care providers to facilitate transition into other services.
The 12 principles of a good death were outlined in an editorial in 2000 (Box 21.1.1) [2]. These apply equally to unexpected and expected deaths. Death in an emergency department of necessity violates some or all of these principles. Emergency physicians should apply these to practice as best they can within the constraints of a busy, crowded emergency department.
Box 21.1.1
Principles of a good death (adapted from Smith [2])
To know when death is coming and to understand what can be expected
To be able to retain control
To be afforded dignity and privacy
To have control over pain and symptom relief
To have choice and control over where death occurs
To have access to necessary information and expertise
To have access to required spiritual or emotional support
To have access to hospice care in any location
To have control over who is present and who shares the end
To be able to issue advance directives that are respected
To have time to say goodbye and control over timing
To be able to leave when it is time to go and not have life prolonged pointlessly
Adapted from Smith R. A good death. British Medical Journal Jan 2000 Vol 320 pp129–130 with permission.
Quality management of grief states can prevent significant morbidity, as pathological or unresolved grief can lead to later problems with physical and mental health.
The death process
Diagnosing dying
Death does not occur at a finite moment. Cardiac death, cerebral death, brainstem death and cellular death form a continuum over minutes or hours. Considerable effort has gone into diagnosing death. Legal definitions for diagnosing brain death, cardiac death and the staff involved are outlined in the relevant transplantation and organ donation acts in various jurisdictions. This has been done largely to facilitate organ transplantation.
There is a paucity of research in the area of diagnosis of the dying process and the part emergency physicians can play in this. Diagnosing dying is a skill best exemplified by specialists in palliative care. It can be hard to estimate and comes with experience. Making this diagnosis can enable the emergency physician to engage patients on a dying trajectory and allow them to take control and plan for the time they have remaining (see Chapter 21.6).
Managing the dying process
When the point of dying is reached, the practitioner needs to be acutely aware of the needs of the dying person. While physical needs, such as analgesia, are relatively easily met, other domains can easily be ignored.
For patients whose death is inevitable or not unexpected, a protocol, such as the Liverpool care of the dying pathway, can be instituted in the emergency department [3]. This tool focuses team care on the needs of the dying patient and avoids unnecessary interventions. The intent is to provide hospice level care in other clinical settings. At this point, the principles of a good death can act as an aspirational target as clinicians attempt to rationalize the care provided to patients.
A large family may need significant space, which can interfere with the routine work of the ED so a private room should be available. Then all can pay special attention to physical comfort, symptom management, privacy and the confidentiality of the patient and family.
Death
Families should be encouraged to be present during resuscitation efforts. A senior support person should be available for the family if at all possible during this time. If the outcome is hopeless, family members can be encouraged to be involved in decision making around abandoning resuscitation. After death, families should be encouraged to view, touch and talk to the deceased. It is well recognized that this improves the grieving process. They will remember these moments for the rest of their lives. Having participated in the resuscitation and in the decision to stop can be helpful
Initiation of the grieving process
Quality management of grief states can prevent significant morbidity, as pathological or unresolved grief can lead to later problems with physical and mental health. Emergency physicians have a duty of care to the survivors to play their part in the initiation of family grief.
Grief is not like an illness, to be fought and cured as so often is the case in Western medicine. Generalizations can be made about human behavioural tendencies and time lines can be drawn for predicted recovery, but each person’s grieving process is unique. Some people never get better and nobody survives grief unchanged.
All relatives need time to receive the clear message of death, which they may need to be given again and again. Some need to make meaning of the event and the clinical art of managing perceptions is paramount. For the families of the deceased, this time will be recalled with unrivalled clarity. It is a great privilege to be part of those memories and it carries the responsibility to manage the family in keeping with best practice principles for the initiation of grieving.
Breaking bad news
The interview with the family of the recently deceased can be more difficult than the resuscitation. Handled with sensitivity, however, it can be a positive start to successful grieving and recovery.
The room in which such information is given should be private and comfortable and contain a telephone. Tea, coffee, iced water and simple food should be readily available. If refreshments arrive soon after the news has been broken, this can help diffuse tension. The offering of food is a time-honoured expression of warmth and comfort and facilitates communication and the grieving process.
The emergency physician should greet the family by name, confirm the relationship of each with the patient and shake hands or touch them gently. All parties should be seated and a helpful way to start is to ask the family members what they know. They may have been present at the scene, where CPR was under way, or have come to hospital independently with no preconceived ideas. A simple unambiguous summary of events should be given. This often needs to be repeated and the family members given time to ask questions.
It is important to use the word ‘dead’ or ‘died’; euphemisms such as ‘passed away’, ‘she’s gone’ and ‘departed this life’ are unclear messages that can mislead. The grieving process cannot start until there is acknowledgement of death. A truthful explanation can be comforting. There is no curriculum for teaching this type of interaction. Junior staff should be able to be present when a more senior staff member is conducting these discussions to facilitate role modelling. Over time, junior staff should be encouraged to facilitate these discussions in the presence of more senior mentors.
Tranquillizers
Requests for tranquillizers can come from survivors or a third party, who may ask that the bereaved be given sedation. It is now recognized that the use of anxiolytic medication is contraindicated in early grieving. This must be carefully explained to families when it is requested. It may be part of the management of morbid grief weeks or months later but has no place in early management. Anxiety, sadness and insomnia can be a natural part of early grief.
Reactions
There is a range of responses to the information that a close relative has died. The mode of death can be a guide. Homicide can lead to great distress, along with suicide and unintended injury. Some common reactions are:
Disbelief: some will immediately deny the event, claiming that it must be somebody else or that they are dreaming. Reinforcement is required.
Numbness: some sit mute, appearing not to take in the information. They need time to absorb it.
Expressive: a sudden flood of tears or loud cries with upsetting or disturbing noises should be allowed to run its course. Such acknowledgement can be a positive response.
Guilt: particularly with homicide and suicide, such news is often followed by ‘if only’ or ‘why couldn’t I have?’ Here, gentle repeated reassurance and discussion can be important. These people are at risk of pathological grief reactions and can be helped by seeing the body and talking to it.
Displacement activity: an immediate call to inform relatives, organize the funeral and discuss family matters is a poor prognostic sign. These people are often seen as mature, rational and born organizers, but they are at risk of pathological grief reactions months later. They will need careful follow up to see that they grieve eventually.
Offers of follow up can be made at this time. If the family members have unresolved questions they need a contact in the emergency department to arrange further meetings if required.
Viewing the body
Relatives and their invited friends should be encouraged to view the body. By seeing the body, by feeling and touching, the grieving process, separation and rebuilding can start. People should be encouraged to speak, touch, kiss, stroke, caress, even to argue, negotiate and cajole in private for as long as they wish. This facilitates natural grieving. The presence of a bereavement or viewing room can make this process much easier as, particularly with children, visiting can go on for several hours. A hospital morgue may be used, some have a purpose-built facility and appropriate staff support. Relatives should be informed of the necessity for police involvement if the matter has been referred to the coroner.
Cultural issues
Various ethnic and religious groups have differing practices for the handling and disposal of bodies. Emergency physicians should be able to manage different family requests in a sensitive manner while bearing in mind local statutory obligations.
For Australians of Aboriginal or Torres Strait Island descent, cultural practices and beliefs vary from region to region and families will guide practitioners. In larger hospitals, Aboriginal liaison services can help.
Death certificates
Doctors managing deaths in the ED must understand and have a sound knowledge of reporting requirements for the coroner’s court (see Chapter 25.2 The coroner). Any death suspected to be not entirely from natural causes or where the cause is unknown requires reporting. Local regulations stipulate the circumstances under which a death certificate may be issued and by whom. For instance, in some states, it is not necessary for the issuer to have seen the person while alive. Coroner’s courts are proactive in assisting medical practitioners to complete certificates where possible.
Organ donation
A thorough knowledge of local definitions is crucial for the emergency physician to participate in efforts to improve organ transplantation rates (see Chapter 21.7). Relatives can ask later why donation was not suggested and some really appreciate the opportunity to contribute to the welfare of others. All Australian states have access to professional transplant coordinators to facilitate the process once permission has been obtained.
Bereavement counselling
Most hospitals have qualified practitioners to support the recently bereaved. Referral should be arranged prior to departure if counsellors have not already made contact. Ministers of religion are trained in grief counselling and are usually available after hours. People can feel unprepared to ask for them and it is not necessary for the deceased to have had any religious affiliation to make use of such counsellors. The general practitioner is also a useful resource and should always be informed promptly of the death of a practice patient. Social workers are expert in grief counselling and many funeral companies and coroner’s offices now provide counselling services.
Subsequent issues
Permission to leave
Recently bereaved people are sometimes confused, frightened, stunned and at a loss as to what to do next. When forensic issues (identification and statements) and viewing have been completed, they can be given the dead person’s possessions and politely given permission to leave the hospital. ‘There is nothing more you can do’ or ‘Can I phone someone or get a taxi to take you home?’ may be usefully offered.
Information about contacting a funeral office to arrange for collection of the death certificate and the body and to discuss burial rites should be in an explanatory leaflet, readily available.
Professional issues
One of the important aspects of looking after survivors is caring for the carers, who are often overlooked. Patient death has been reported to lead to physical and emotional symptoms in emergency medicine practioners [4]. There is no evidence that psychological debriefing prevents or ameliorates post-traumatic stress disorder and it may cause harm to some. Often, after an unsuccessful resuscitation, professionals need to talk about the events within the team environment. This should be done to foster reflective practice around teamwork in crisis situations. It is uncertain whether this improves psychological outcome. There is, however, a distinct propensity for those who spend their lives among misery to become cynical and full of black humour. The cultural norms of emergency medicine can become so integrated into personal values that the physician does not even recognize their presence. We should regularly assess our own emotional fatigue and, if there is a significant divergence between our personal values and career activities, we may be motivated to seek support from a trusted source. This area awaits further research.
Controversies and future directions
The role of protocols, such as the Liverpool care of the dying pathway, in emergency medicine is currently unclear and is controversial in some health systems where it has been implemented. The challenge for emergency physicians is to improve the care of the dying in our busy emergency departments.
Increasingly, attention will be paid to ensuring the well-being of staff who are constantly exposed to death and dying in the course of their duties.
References
1. Australian Institute of Health and Welfare: Australian hospital statistics 2011–12: emergency department care<http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423039>.
2. Smith R. A good death. Br Med J. 2000;320:129–130.
3. Marie Curie Palliative Care Institute. Liverpool care pathway for the dying patient.<http://www.liv.ac.uk/mcpcil/liverpool-care-pathway>[Accessed Jan. 2013].
4. Strote J, Schroeder E, et al. Academic emergency physicians’ experiences with patient death. Acad Emerg Med. 2011;18:255–260.
Further reading
1. Carey G, Sorensen R, eds. The penguin book of death. Melbourne: Penguin Books, Melbourne University Press; 1997.
2. Shears R. Emergency physicians’ role in end-of-life care. Emerg Med Clin N Am. 1999;17:2.
21.2 Sexual assault
Ian Knox and Roslyn Crampton
Essentials
1 Sexual assault is defined as an act of a sexual nature carried out against a person’s will.
2 There is widespread under reporting of this criminal offence.
3 The complex medical, legal and psychological sequelae mandate a team-based approach for victims involving doctors, police and counsellors in a collaborative effort.
4 Management by a sympathetic non-judgemental physician helps the victim to regain control.
5 The medical evaluation is specifically directed at the issues of injury assessment and management, infection risk and emergency contraception.
6 The forensic aspects of the examination require vigilant examination and documentation by the physician to assist the court in legal proceedings.
Introduction
Sexual assault is defined as an act of a sexual nature carried out against a person’s will. Following sexual assault, a patient presenting should first be evaluated for acute traumatic physical injuries and drug or alcohol intoxication. The victim should be offered prophylaxis for sexually transmitted infection (STI) and pregnancy as appropriate. If required to collect forensic evidence to assist in any police investigation, consent is obtained for recording the victim’s account of the assault, the findings on physical examination and for the collection of forensic material. Follow-up medical care and psychological support should be arranged prior to safe discharge.
Definitions
Every jurisdiction in Australia has its own legislation and definitions used to describe all types of sexual offences. Sexual assault has a number of elements. It is an act of a sexual nature that is carried out against the will of the victim. Consent is the crucial issue. The victim does not give consent, is intimidated to consent, or is legally incapable of giving consent because of youth or incapacity. It includes attempts to force the victim into sexual activity and includes rape (intentional penile penetration of the vagina, including the vulva), attempted rape, aggravated sexual assault (assault with a weapon or infliction of injury), indecent assault (oral or anal intercourse), penetration by objects and forced sexual activity that did not result in penetration. Penetration is not an essential element to sexual assault.
The absence of physical resistance by the victim is not regarded as consent. Consent by intimidation or coercive conduct without physical threat is also a criminal act. Consent requires free agreement and a person may be incapable of consenting because of the influence of drugs or alcohol.
Sexual assault by a carer upon a child is termed sexual abuse. This is sexual activity in which consent is not at issue and involves the child in sexual activity that is either beyond the child’s understanding or contrary to accepted community standards. There are legal definitions regarding age, generally in the order of 15–17 years depending on the jurisdiction. Sexual violence involving a disabled person may also be either abuse or assault depending on the nature of the act or the circumstances of the victim.
Epidemiology
Global statistics indicate at least one in five women experiences rape or attempted rape during her lifetime [1]. Crime statistics are limited; it is estimated, for example, in the Australian Bureau of Statistics Personal Safety Survey 2005 that only 19% women who were sexually assaulted reported the incident to police [2]. Victims hesitate to report because of humiliation, fear of retribution, fear they will not be believed, self-blame and lack of understanding of the criminal justice system.
In this survey, based on sampling the Australian population of women, 5.8% (443 800) experienced violence in the previous 12 months, including 1.3% experiencing sexual assault. Males experienced sexual assault less frequently at 0.6%. For females, only 22% were assaulted by a stranger, 21% by a previous partner, 39% by a family member or friend and 32% by another known person. Stranger assaults were more common in males (33%). An estimated 17% of women had experienced sexual assault since the age of 15 versus 4.8% of men.
Sexual assault is more common in vulnerable populations. Individuals in psychiatric facilities may be targeted and their report may not be believed as may occur with intellectually or physically disabled persons with diminished ability to detect or escape from such danger. Homeless women with serious mental illness have a very high lifetime risk for this violent victimization. Young adult male prisoners are also at risk [3].
Barriers to care
The ABS study [4] found that once an incident of sexual assault has been reported to the police, one in four cases result in the perpetrator being charged, but the conviction rate is low with less than 50% of defendants found guilty. The study showed 12.5% of women also did not report the assault to the police because of shame and embarrassment. Emergency physicians and nurses need to be aware of these attitudes that the victim and they themselves may have when approaching the sexual assault victim. A non-judgemental, accepting stance by care providers is essential. The victim has enough self-doubt without healthcare providers adding to that. It is not the health professional’s role to make a judgement as to whether the rape occurred; the courts will decide this. False allegations of rape are made, but given the perceived penalties associated with reporting a rape, such a person is likely to be disturbed and in need of help in any event.
The role of the doctor in attending to victims of sexual assault who have consented to forensic examination and evidence collection is not the usual model of a therapeutic relationship. There is a dual obligation, as it is recognized that they have both a therapeutic role and a duty to the court to provide completely objective expertise in collecting evidence and interpreting the findings on examination to a court of law, where the impartiality of experts is key to their duty.
Consent
Victims who experience sexual assault may have experienced a loss of control and feel in danger. For the person to regain control, every step of the process must be explained and consent gained. Consent must be obtained for the forensic examination and evidence collection and for the release of the information to the police. Consent must be informed, specific and freely given. The consent must be witnessed. The capacity of the victim to give consent has to be carefully assessed. The mental competence to understand the information can be impaired, for example, by drugs or alcohol and mental state should be first tested. Certain patients are bound by formal legal requirements, which vary in each jurisdiction, for consent or responsibility for medical treatment. These include intellectually disabled persons, psychiatric patients under involuntary admission and children under custody orders or under the care of the state.
The evidence collected under this consent must be accurately labelled and secured.
Chain of evidence
Once a forensic specimen has been collected from its origin, all aspects of its existence must be recorded. All persons coming into custody of the specimen must be identified and the details of all transfers of custody and maintained security of the material must be recorded. A forensic register must be maintained for all items in a dedicated and secure storage facility.
Medical evaluation of the victim
The medical, forensic and psychological needs of a complainant depend on the nature and timing of the assault. The immediate medical needs are paramount. Medical care for victims of sexual assault includes consideration of physical injury, toxicological issues and the risks of acquiring an infection or pregnancy.
Evaluation of acute traumatic injuries is the first priority. The literature typically describes about half the victims having some sort of physical injury [5], although less than 5% of victims require admission to hospital for treatment. An analysis of over 1000 cases in the USA [6] revealed that physical examination showed evidence of general body trauma in 64% of victims. Genital trauma was noted in 52%, while 20% had no injuries documented. An Australian study confirmed non-genital injuries in 46% of women and genital injury in only 22% [7]. These findings indicate that many sexual assault victims may not have either general or genital trauma on examination and this absence does not mean that an assault did not occur.
Potentially life-threatening injuries may include attempted strangulation, blunt traumatic injury to the head or face and torso and penetrating injuries, which may be occult. These should be fully evaluated prior to referring for forensic processes.
A study from Florida found that one in 1500 sexual assaults resulted in the death of the victim, with asphyxiation being the most common cause of death. While there has been no comparable Australian study, the Australian Institute of Criminology reports that there were 288 homicides committed in Australia in 2003 and a sexual assault was the precipitating factor in nine [8].
Non-fatal strangulation is an important risk factor for homicide of women [9]. Of 300 survivors of strangulation reported from the San Diego City attorney’s office [10], 150 had no visible markings. Examination findings, where present, can include ligature abrasions, finger tip bruising from the assailant’s grasp and curvilinear abrasions caused by finger nail markings, occurring singly or in sets, caused by the victim’s struggle to pry the grasp from her neck. Subconjunctival haemorrhage and petechial haemorrhages in the skin may be identified.
Strangulation is a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure usually by hands (throttling) or ligature strangulation (garrotting). External injury may appear trivial but is a marker of potentially significant sequelae that can develop in surviving victims, both acute and delayed.
Compression of the airway can lead to laryngeal injuries including fractures, soft-tissue swelling and mucosal oedema with potential development of airway compromise. Significant gulping of air together with vomiting and an episode of loss of consciousness may precipitate aspiration. Hypoxic cerebral damage depends on the duration of hypoxia and most victims either die or survive without obvious brain damage, but post-hypoxic encephalopathy has been reported. Carotid artery intimal dissection with subsequent thrombus formation has also been reported. This may present as a delayed focal deficit from subsequent stroke up to 2 weeks after the incident [11]. Attempted strangulation warrants a high index of suspicion to rule out injuries and a period of observation may be required.
Penetration with foreign bodies can cause overt or occult pelvic injury. Further investigation or operative intervention may be necessary.
Forensic history, examination and evidence collection
The forensic examination is carried out for the purpose of obtaining evidence of the rape or assault that could be used in a prosecution. The aim is to record the victim’s report of the assault and collect and record evidence related to this report and collect DNA. Specific consent should be sought before this examination is undertaken, as therapeutic benefit is not intended. Specific consent must be additionally obtained to turn over the specimens to the police. Police services produce kits that give a comprehensive guide to the history and examination including body charts required for various aspects of the prosecution. Emergency departments should have access to a multidisciplinary team with a clinician trained in such collection.
Physical examination recorded for the forensic record must include every wound detected on meticulous forensic examination. Injury could have been inflicted by the assailant or in the victim’s attempted defence or escape; in the interpretation of the injury, even minor wounds that may not require treatment take on key forensic significance. Physical examination requires a sympathetic but professional and methodical approach of every body surface as with the collection of relevant forensic samples. Every injury must be carefully recorded on a body chart. Height and weight is required for interpretation of toxicological results.
Standard nomenclature including lacerations, abrasions and bruises should be used in wound description. Correct anatomical sites must be recorded and labelled in genital examination. Evidence collection kits provided in each jurisdiction contain anatomical body charts for recording all body areas, which must be assessed for evidence of injury including the ears, mouth and throat.
A wound is a disruption in the continuity of tissues produced by physical injury. Description of the physical characteristics of a wound includes the site, size, shape and depth of the wound as well as the appearance of the wound edges and adjacent tissue, the contents of the wound and whether there is evidence of healing.
An abrasion is a superficial injury of the skin caused by pressure and movement applied simultaneously. Abrasions can be of importance in the forensic context, as they may identify direction, as with friction abrasions, or patterns of the causative object as with imprint abrasions or they may contain embedded trace materials.
A bruise is an area of haemorrhage within or beneath the skin due to blunt trauma. This is also known as a haematoma, contusion or haemorrhage. The discoloration is caused by blood leaking from damaged blood vessels. The age of a bruise cannot be determined by its colour as this can undergo considerable variation. It takes more than 18 hours to develop any yellow discoloration [12]. Bruises may not occur at the site of the trauma and their size does not always correlate with the applied force; they may be altered by coincident conditions, such as anticoagulant therapy.
A laceration is a ragged or irregular tear in the skin, subcutaneous tissue or organs resulting from blunt force. Lacerations can be distinguished by irregular or crushed margins, bands of intact tissue forming bridges across the wound and intact structures, such as tendons, within the wound. The term laceration is often misused to describe an incised wound. An incised wound is an injury produced by sharp-edged objects. The edges of incised wounds are sharply defined and blood loss may be extensive as the vessels are divided rather than crushed. The correct classification of injuries can assist in determining the mechanism of injury or the object or weapon that caused the injury.
Patterns of injury may be observed. Blows to the head, face and neck may cause bruising, lacerations and fractures and include hyphaemas, dental trauma and tympanic membrane perforation. Fingertip bruising and imprint bruising may be evident. Defensive responses may show warding off injuries to the hands, for example, incised wounds to the palm or bruising on extensor surfaces of the arms. Fingertip bruising can be present on the medial thighs. Bite marks may be seen on breast or buttocks. Abrasions from contact with unshaven skin may be detected. Postmenopausal women are significantly more likely to need surgical management and repair of genital injuries than are younger women [13].
Examination of the genitalia includes inner thighs, buttocks and anus. Common locations for genital injuries include tears or abrasions of the posterior fourchette (where the two labia meet posteriorly), abrasion or bruising of the labia minora and fossa navicularis (directly anterior to the fourchette) and bruising or tears of the hymen. After relevant forensic specimens have been collected, it may be necessary to use a Foley catheter to tease out any folds in hymenal tissue to facilitate the inspection of hymenal injury. An examination of the vagina and cervix can then be completed using a speculum, any evidence of injury recorded and any bleeding or discharge recorded with the source identified. Perianal injury may need a moistened swab to tease out folds for inspection and proctoscopy may be required for inspection as appropriate.
Despite the relatively low frequency of obvious injury, the documentation of such injuries increases the chance of successful prosecution [14]. Photography must have the specific consent of the victim and is best performed by an experienced practitioner and the secure storage of images must be ensured.
Collection of forensic specimens
The perpetrator may have left evidence on the victim. Sampling from sites of contact between the victim and assailant is the basis of evidence collection. Specimens collected are guided by the circumstances. Standardized evidence collection kits used in each jurisdiction contain both forms of swabs and slides appropriate to obtain trace evidence of saliva, semen, blood and skin-to-skin contact. Samples should be sampled, allowed to dry, sealed and packaged with all contents carefully labelled and the chain of evidence maintained. Slides should be made where the presence of semen is suspected.
Any sample collected from the victim that contains cellular material from the victim’s assailant can be used for DNA testing. This includes spermatozoa, semen if it contains cells or blood or tissue from under fingernails, which should be clipped. DNA evidence left on or in the body of a victim, particularly in moist areas, degrades quickly over 2–10 days. The forensic assessment should thus be made as soon as possible. Underpants and panty liners worn during or after the assault may be contaminated with forensic material and should be retained. As DNA degrades quickly if moist, with the overgrowth of organisms, underclothes should be stored in paper not plastic bags.
Proof of sexual contact is established by the detection of spermatozoa or semen either on or within the victim or on the victim’s clothes. The likelihood of detecting spermatozoa or semen from the vagina is generally very low by 72 hours. However, under some circumstances, spermatozoa may persist for days longer and can be obtained from the endocervical os or cervix. The detection of sperm or semen from the rectum or mouth is possible but very dependent on the actions of the victim after the assault, which should be recorded. The presence of DNA in deposited saliva may give a positive result for up to 2 days. Skin swabs for epithelial cells are generally unhelpful after 12 hours.
Care must be taken when the victim undresses for the examination. Hair or clothes fibres from the offender or other traces from the crime scene may have adhered to the body or clothes of the victim. The victim should undress standing over a drop sheet, which should then be included in a bag into which clothes are placed. This becomes part of the physical evidence.
The most accurate laboratory method currently available to identify the assailant is DNA testing. The chance of incorrectly identifying an alleged assailant as the source of DNA material is very small. However, the risk of contamination of the evidence samples with that of DNA belonging to other individuals is significant and has resulted in wrongful incarceration [15]. Accordingly, forensic collection and analysis techniques are under increasing scrutiny by the legal system and sources of contamination must be excluded. All measures to minimize DNA cross-contamination in the clinical setting, including the consistent use of gloves, gowns, mask and drapes and in the techniques of collection must be taken and recorded.
Toxicological issues
Drugs may be administered to the victim in order to facilitate sexual assault. The commonest drug is alcohol, but large numbers of drugs, including flunitrazepam and gamma hydroxybutyrate (GHB), have been implicated and the victim may be unaware or have no memory of events surrounding the assault. Self-reported alcohol consumption immediately prior to assaults is very common, including up to 77% of those reporting drug-facilitated sexual assault [16] and this study revealed levels in 37% of those reporting with an average blood alcohol concentration of 0.11% at the time of examination. This is likely to have had a significant impact on conscious state and the ability to consent at the time of assault and may impair the victim’s subsequent recall of events. The victim is at additional risk, particularly where there is a combination with prescription or recreational drugs. Covert administration of drugs in the setting of sexual assault appears uncommon in this Australian study. The interpretation of drug levels and their possible effects is difficult. In general, urine is the preferred specimen, although blood samples should be collected within 24 hours of the assault and these must be refrigerated prior to laboratory analysis.
Medical aftercare
The risk of genital infection after sexual assault
The risk of sexually transmitted infections (STIs) following rape is reported to be 4–56%, with infection reflecting those organisms that are locally prevalent. One study showed that with baseline testing, 43% of victims had evidence of pre-existing infection [17]. The finding of pre-existing infection is not admissible in court under Australian law. Most experts discourage testing for STIs in the emergency department unless symptomatic.
Baseline screening [18] for the following infections is recommended in follow up:
HIV: HIV antibody
Hepatitis B: hepatitis B surface antigen, HbsAg, core antibody, anti-HBc and surface antibody, anti-HBs
syphilis: rapid plasma reagin (RPR) and Treponema pallidum haemagglutination assay (TPHA)
chlamydia: polymerase chain reaction (PCR) endocervical swab, first void urine
gonorrhoea: endocervical swab, PCR and microscopy culture and sensitivity
trichomonas: high vaginal swab, microscopy culture and sensitivity.
While the risk of acquiring an infection is difficult to define, antibiotic prophylaxis is not generally recommended for the victim unless the person committing the assault is known to be suffering from an STI, is at high risk for having an STI or it is thought unlikely to return for follow up. Poor follow-up rates are the norm and all patients should be offered prophylaxis in the emergency department if urgent follow up cannot be ensured. Intramuscular ceftriaxone 250 mg together with 1 g azithromycin orally plus either metronidazole 2 g or tinidazole 2 g as a single dose is the suggested antibiotic regimen [19].
Given the low prevalence of syphilis in the general community, it is reasonable not to give benzathine penicillin routinely but to have syphilis serology performed at 3 months, depending on the circumstances and whether follow up can be assured. Chlamydia trichomatis is the most common notifiable sexually transmitted infection in Australia. If the victim has a pre-existent infection and receives treatment with azithromycin without follow up or contact tracing there is a risk of re-infection and increased risk of serious morbidity, including infertility.
Hepatitis B virus can be transmitted by sexual intercourse but the risk of transmission is undefined. By comparison, the risk of infection following a percutaneous needle stick from an HBAg-positive individual to an HBAb-negative recipient is 5–43% [20]. Prophylaxis with hepatitis B vaccine 1 mL IM is indicated. HBV vaccination and hepatitis B immune globulin (HBIG) (400 IU IM) should be available where the assailant is either known to be HBV positive or the woman is considered to be particularly at risk of infection. Hepatitis B vaccination without HBIG is highly effective in preventing HBV infection in sexual contacts of persons who have chronic HBV infection. Persons exposed to an assailant with acute HBV infection additionally require HBIG which prevents 75% of such infections [21]. Unless victims have a reliable vaccination history and serological conversion, the full hepatitis B course should be initiated, even when the completion of the vaccine series cannot be ensured [22]. Hepatitis C is not efficiently transmitted sexually.
It is likely that the victim will be concerned about HIV or will become concerned at a later date. The offer of HIV testing should be made accompanied by the usual full explanation and written consent needs to be obtained if the test is done. HIV seroconversion has occurred in persons whose only known risk factor was sexual assault, although the frequency of this occurrence is thought to be low [22]. In consensual sex, the risk for HIV transmission from vaginal intercourse is 0.1–0.2% and for receptive anal intercourse 0.5–3.0%. The risk of transmission from oral intercourse is much lower. Specific circumstances of an assault that might increase risk for HIV transmission include the site of penetration, site of exposure to ejaculate and the presence of mucosal trauma, genital lesions or another STI.
Other factors that should be considered in the recommendation for post-exposure prophylaxis (PEP) include multiple assailants, the likelihood of an assailant having HIV given the local epidemiology for HIV and whether the assailant is from a high-risk group including men who have sex with men or use drugs by injection.
HIV PEP should be offered as soon as possible after the assault up to 72 hours post-exposure. PEP appears to be well tolerated. Local protocols for the initial 3–5-day medication supply, collection of baseline testing and prompt referral for specialist consultation must be in place. National guidelines [23] recommend the use of two and three antiretroviral drug regimens according to the calculated risk of HIV exposure, increased to a three-drug regimen using stavudine 40 mg twice daily when calculated exposure risk exceeds 1 in 1000. The full 28-day course must be undertaken with both regimens.
Tetanus prophylaxis must be considered as part of the management of any injuries in the usual way.
Pregnancy prophylaxis
The risk of pregnancy following a single unprotected episode of coitus has proven difficult to define. However, a large prospective study from North America rated the risk of pregnancy from rape as 5% [24]. Emergency contraception is readily available in Australian pharmacies and it is the responsibility of the medical practitioner to ensure the patient knows of the availability and has immediate access to the medication.
The progestagen levonorgestrel is used alone for emergency contraception in a dose of 1.5 mg and can be given up to 5 days from the time of unprotected intercourse. If this single dose is given within 72 hours, the proportion of pregnancies prevented was 85% in the WHO multicentre study [25]. The earlier it is given, the more effective it is.
The literature demonstrates that there is poor compliance with follow-up instructions in this setting. Arrangements for follow-up testing for pregnancy, sexually transmitted diseases, HIV and hepatitis B vaccination should be supplied as written instructions as victims may subsequently remember little of their interview.
Crisis intervention
Acute reactions to rape range from emotional numbing to shame, self-blame and severe emotional distress. The predominant reaction is a devastating sense of loss [26] based on the fear for survival and the gross invasion of bodily boundaries which removes the victim’s control over that which she finds most personal to her. Longitudinal data [27] suggest sexual assault survivors are at increased lifetime risk of post-traumatic stress disorder (30%) and major depression (30%). The input of sexual assault counsellors in evaluating the patient’s immediate and ongoing emotional and safety needs must be in place prior to discharge. The role of various psychological therapies in decreasing long-term sequelae is not yet clear.
It has been found that the greater support the doctor provides the victim, the better the outcome [28]. However, this study found doctors were the least supportive health professionals in this setting.
Children
Child sexual assault is ideally managed by a team with specific paediatric expertise. The circumstances regarding children who are the victims of sexual assault differ from those relating to adults. First, the child is likely to have been the victim of chronic abuse rather than an attack by a stranger. Second, almost always the offender will be a man known to the child, often in a position of authority and trust. This introduces the issue of protecting the child from further molestation. The injury pattern is highly variable. Chronic sexual abuse tends to develop as a pattern of behavior between the victim and the offender beginning with touching and possibly leading to penetrative intercourse. This escalation of activity may evolve over a lengthy period and physical trauma may not be a feature. If the child has been the victim of a stranger assault, the risk of physical injury is greater than for an adult victim [29].
Conclusion
A patient presenting for care after sexual assault should first be evaluated for acute traumatic injury and any intoxication issues. The victim should be assessed in order to offer appropriate post-exposure prophylaxis to pregnancy and sexually transmitted diseases including gonorrhoea, chlamydia, trichomoniasis, hepatitis B and HIV, plus routine tetanus prophylaxis. Specific informed consent must be obtained prior to forensic evaluation. The involvement of a multidisciplinary team with an experienced forensic examiner and sexual assault counsellor is of value. Discharge must not occur until the immediate safety of the victim is ensured. Follow up for medical issues and ongoing psychological support should be arranged prior to discharge. Maintaining a sympathetic non-judgemental approach by the physician improves the victim’s outcome.
Controversies and future directions
The incidence of sexual assault has previously been under recognized in the disabled, mental health inpatients, military and police recruits in academies and a range of other institutional and educational settings.
One of the most challenging areas is the endemic problem of violence, including sexual violence inflicted on indigenous women. Some groups of Aboriginal girls and women report that half of them have been the victims of incest or sexual assault. Crime statistics recorded in 2008 found that the indigenous victimization rate for sexual assaults in NSW was nearly 3.5 times the rate for the non-indigenous population [30].
It is now recognized that every precaution must be taken to reduce possible cross-contamination of DNA during collection and storage of forensic specimens.
References
1. International Medical Advisory Panel. Statement of gender based violence. London: International Planned Parenthood Federation; 2000.
2. Australian Bureau of Statistics. Personal safety survey Australia. ABS Catalogue 4906.0 Commonwealth of Australia; 2005.
3. Heilpern D. Fear or favour: sexual assault of young prisoners Southern Cross University Press 1992.
4. Australian Bureau of Statistics. Sexual assault in Australia: a statistical overview. ABS Catalogue 4523.0 Commonwealth of Australia; 2004.
5. Rambow B, Adkinson C, Frost TH, et al. Female sexual assault: medical and legal implications. Ann Emerg Med. 1992;21:727–731.
6. Riggs N, Houry D, Long G, et al. Analysis of 1076 cases of sexual assault. Ann Emerg Med. 2000;35:358–362.
7. Palmer C. Genital injuries in women reporting sexual assault. Sexual Hlth. 2004;1:55–59.
8. Australian Institute of Criminology. Homicide in Australia 2003–2004. National Homicide Monitoring Program. Research and Public Policy Series No. 66.
9. Glass N, et al. Non fatal strangulation is an important risk factor for homicide of women. J Emerg Med. 2008;35:329–335.
10. Hawley D, Mc Clane E, Strack G. A review of 300 attempted strangulation cases part III. J Emerg Med 21: 315.
11. Malek AM, et al. Patient presentation angiographic features and treatment of strangulation induced bilateral dissection of the internal carotid artery. J Neurosurg. 2000;92:481–487.
12. Langlois NE, Gresham GA. The aging of bruises a review and study of the colour changes with time. Forens Sci Internatl. 1991;50:227–238.
13. Ramin SM, Satin AJ, Stone IC, et al. Sexual assault in postmenopausal women. Obstet Gynecol. 1992;80:860–864.
14. Linden JA. Care of the adult patient after sexual assault. N Engl J Med. 2011;365(9):834–841.
15. Vincent FHR. Inquiry into the circumstances that lead to the conviction of Mr F.A.J. Victorian Government Printer; 2010.
16. Hurley M, Parker H, Wells DL. The epidemiology of drug facilitated sexual assault. J Clin Forens Med. 2006;13:181–185.
17. Hampton HL. Care of the woman who has been raped. N Engl J Med. 1995;332:234–237.
18. Mein J, Palmer C, Shand MC, et al. Management of acute adult sexual assault. Med J Aust. 2003;178:226–230.
19. Workowski KA, Berman S. Sexually transmitted disease treatment guidelines, 2010. Centers for Disease Control and Prevention. Morbid Mortal Wkly Rep 2010; 59:91.
20. Gerberding JL, Henderson DK. Management of occupational exposures to blood-borne pathogens: Hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Clin Infect Dis. 1992;14:1179–1185.
21. Centers for Disease Control and Prevention. Post-exposure prophylaxis Hepatitis B Recommendations and reports. Morbid Mortal Wkly Rep. 1997;47:101–104.
22. Centers for Disease Control. Post-exposure prophylaxis Hepatitis B. Recommendations and reports. Morbid Mortal Wkly Rep 2010; 59:80–8.
23. Australian Government Department of Health and Aging. National Guidelines for post exposure prophylaxis after non occupational exposure to HIV. Copyright Commonwealth of Australia; 2006.
24. Holmes MM, Resnick HS, Kilpatrick DG, et al. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175:320–325.
25. Von Hertzen H, Piaggio G, Pregoudov A, et al. Low dose mifeprostone and two regimes of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002;360:1803–1810.
26. Rose DS. Worse than death: psychodynamics of rape victims and the need for psychotherapy. Am J Psychiatr. 1986;143 817–4.
27. Linden JA. Care of the adult patient after sexual assault. N Engl J Med. 2011;365:834–841.
28. Popiel DA, Susskind EC. The impact of the rape: social support as the moderator of stress. Am J Commun Psychol. 1985;13:645–676.
29. Cartwright PS, the Sexual Assault Study Group. Factors that correlate with injury sustained by survivors of sexual assault. Obstet Gynecol. 1987;70:44–46.
30. Australian Bureau of Statistics. Recorded Crime: Victims. Catalogue No 4510.0, 22. Commonwealth of Australia; 2008.
21.3 Family violence
Sandra L Neate, Lyndal Bugeja and Carolyn Walsh
Essentials
1 Family violence encompasses physical, sexual and psychological violence.
2 All forms of family violence are inter-related in a complex way. Victims of violence may suffer many forms of abuse over their lives.
3 Between 30 and 50% of women and approximately 15% of men experience family violence over their lifetime.
4 Family violence occurs across all socioeconomic, religious and cultural groups.
5 There is a range of barriers to disclosure and reporting to authorities.
6 Effectively responding to family violence requires a multidisciplinary and coordinated approach, involving health practitioners, social services and justice agencies.
Definition
Family violence involves all types of violence within intimate or family relationships. It includes physical and sexual abuse, threats and intimidation, psychological, emotional and social abuse and financial deprivation and can occur across the lifespan [1].
Physical violence is defined as intentionally inflicted harm using bodily force or a weapon. It encompasses sexual violence, such as non-consensual or coercive sexual activity using physical force, sexual harassment, stalking, forced or deceptive sexual exploitation, threats or intimidation [2] and non-personal violence, such as intentional property damage. Psychological abuse, which frequently precedes physical abuse, may take the form of threats, verbal harassment, ridicule or behaviours designed to intimidate, humiliate, control and isolate the victim.
Family violence most often occurs within current or former intimate relationships and is described as a gendered phenomenon, as it is largely perpetrated by men against women [3]. However, while women account for the larger proportion of victims, males can also be affected [4] and this form of violence may also feature in same sex relationships [5]. Family violence may involve any family member related by blood or law. Children may be directly victimized or suffer harmful consequences as a result of hearing or witnessing violence [6].
The subjective experience and definition of family violence are strongly influenced by cultural beliefs and previous life experiences and the individual’s perceptions of their experience may vary greatly.
Family violence is also referred to as domestic violence or intimate partner violence. The more inclusive term of family violence accounts for violence within a range of intimate and family relationships.
Incidence
The prevalence of family violence varies according to definition (whether sexual and emotional abuse are included), timing of the abuse (current, during adult life or cumulative life time prevalence) and whether the violence is actual or threatened. Australian prevalence surveys indicate that approximately 30% of women and 15% of men report a lifetime history of (actual, personal) family violence, with around 20% of women and 8% of men disclosing a history of family violence during adult life [7,8]. US studies report a higher cumulative lifetime prevalence of approximately 50%, but include actual and threatened, personal and non-personal violence [9].
The 2005 Australian Personal Safety Survey reported that 15% of Australian women had experienced physical or sexual violence by a previous partner and 2.1% by a current partner since the age of 15. In contrast, 4.9% and 0.9% of Australian men had experienced violence by a previous or current partner, respectively [10]. The Australian component of the International Survey of Violence against Women survey reported that 34% of women had experienced physical and/or sexual violence since the age of 16 [3]. The 2005 Personal Safety Survey also reported that 61% of women who had experienced violence had children in their care at the time of the violence and 31% of these children had witnessed the violence. Of women who had experienced violence, 59% had been pregnant during that relationship, 36% reported violence during pregnancy and 17% reported the first instance of violence occurring during pregnancy [10].
Overall, women have a four times higher risk of experiencing family violence than men and those who have been victims of child abuse have six times the risk of experiencing adult family violence. Men and women report a similar incidence of approximately 7% of childhood abuse alone [8].
Approximately 2% of women presenting to emergency departments (EDs) have experienced physical violence within the 24 hours preceding the presentation [7,8]. The incidence is approximately 10% if psychological abuse is included [9].
Vulnerable groups
Certain groups within the population may be more vulnerable to the effects of family violence. Among these are indigenous communities, culturally and linguistically diverse communities (CALD), people with disabilities and the elderly.
Indigenous communities
Members of indigenous communities may be exposed to heightened levels of family violence. In 2010, 14% of Australian homicide victims were identified as Aboriginal or Torres Strait Islander and the majority of these victims (68%) died in a family homicide incident, most commonly involving an intimate partner [11]. One New Zealand general practice survey found a life-time incidence of partner violence of 75% for Maori women [12].
CALD communities
CALD communities experience additional complexities with respect to family violence. While it is important to avoid generalizations and stereotypes, cultural values and beliefs can have implications for the way in which the individual experiences and responds to violence. CALD victims may encounter greater difficulty obtaining assistance and support from mainstream service providers for reasons including: discrimination and marginalization; lack of awareness of legal rights and protections; concerns of bringing dishonour to the family; fear of authority figures; and communication barriers.
Disability
Women with disabilities can be disproportionally affected by family violence. Victims with cognitive and physical disabilities experience greater difficulty in accessing mainstream services due to: communication barriers; lack of appropriate transport and accommodation; reliance on the perpetrator of violence; and limited recognition of their victimization status.
Elderly
The elderly are at risk of abuse from people on whom they depend. Physical or cognitive impairments add to their vulnerability. Older persons can become socially isolated due to a decline in social contacts and supports, increasing the risk that abuse will go undetected.
Risk factor identification
The identification of risk and contributory factors for family violence within intimate relationships has allowed for improved understanding of the nature, form and degree of danger to victims, as well as the conditions under which incidents of family violence are more likely to occur.
While the growing evidence base about risk factors has informed the development of a variety of tools and measures designed to improve and detect those at risk, the presence of these factors is not an infallible predictor of violence. For example, some victims with multiple risk factors will not experience escalating or severe violence, while fatal family violence can occur in the absence of clearly defined risk and contributory factors.
Despite this caveat, knowledge and recognition of these factors is an important step toward improved identification and intervention in violent behaviour. To this end, risk factors are generally classified at the level of the individual, relationship and social environment [13].
Individual level risk factors have been identified for both victims and perpetrators of violence. Individual characteristics associated with men having an increased risk of perpetrating violence are alcohol abuse, drug use, low education standards, unemployment and being a former rather than current partner [12]. Alcohol abuse is the most identifiable risk factor and the risk is proportional to the degree of abuse, although it is not necessarily causal. Pregnancy and new birth have been associated with both emerging and escalating violence [14]. There is some association between perpetrator mental health and violence, particularly conditions such as depression and psychosis [15].
At the level of the relationship, a history of abusive and violent behaviour is one of the strongest predictors of further violence [16]. Separation or the announcement of an intention to end an intimate relationship is associated with an increased risk of violence. Separated or divorced women are four times more likely to be abused than women who have never married, are married or are widowed [17]. Men who are abused are commonly assaulted by the women whom they abuse [18].
Social environment factors affecting family violence include gender inequality supported by societal norms and economic or social policies that create or sustain inequalities [13].
Outcomes
Family violence affects health outcomes in a multitude of physical and psychological ways. Most presentations to health professionals by victims of violence are a complex mix of indirectly related physical and psychological problems and are not trauma related [9].
Physical injury and illness
Physical injuries resulting from family violence may have patterns similar to other forms of non-accidental injury, such as a history inconsistent with the injury, injuries of varying temporal stages or unreasonable delay in presentation. Non-accidental injuries are often in central compared with peripheral areas of the body. Injuries to defensive areas of the body or to the back, legs, buttocks, back of the head and soles of the feet reflect attempts at self-protection. Injuries inflicted on females are likely to be contusions, abrasions, lacerations, fractures and dislocations [19]. Women are more likely to be choked, beaten or sexually abused. Men have a greater risk of having objects thrown at them or weapons used against them. Although family violence-related injuries may follow certain patterns, injury pattern is of low positive predictive value in the identification of family violence [19].
Abuse before, during and after pregnancy represents a threat to the well-being of the mother and baby. Approximately 40% of women who are physically abused are forced into non-consensual sex at some stage. This results in high rates of sexually transmitted disease, unintended and adolescent pregnancy and termination of pregnancy. There is also an established complex link between family violence and preterm labour, low-birthweight babies and postnatal depression [20].
Prevention of access to or interference with general healthcare or antenatal care may occur with up to 17% of abused women reporting partner interference with accessing healthcare [21].
In Australia, homicide among intimate partners and other family members forms a substantial proportion of annual homicide incidents. Between 1989 and 2002, 38% of homicide victims were murdered by a family member [22]. Approximately 25% of USA female homicides are family violence related. Many homicide victims had presented to an ED in the 2 years preceding their death. Documentation of violence and intervention were rare [23].
Psychological impact
Family violence is an independent risk factor for mental illness. Women who have experienced family violence have an approximately 11-fold increase of dissociative disorders, 6-fold increase in somatization disorders, 5 times higher incidence of anxiety and are three times more likely to suffer depression, phobias and drug dependence [17,18]. Exposure to family violence has also been shown to be associated with the onset of post-traumatic stress disorder. Abused women have twice the rates of hazardous alcohol consumption and dependence [17]. Abuse occurring both in childhood and adulthood causes a further significant increase in the incidence of mental illness. The experience of psychological abuse, especially ridicule and humiliation, are particularly responsible for causing low self-esteem.
Impact on children
The impact of family violence on children includes potential victimization, witnessing violence, separations from family, foster care, risks of future mental illness and an increased potential to perpetrate violence in the future [6].
Children living in a home where violence is perpetrated against a parent are 15 times more likely to be a victim of abuse or neglect themselves [20]. Family violence is a risk factor for becoming a perpetrator of homicide in the pre-teenage group [24].
The outcome of the experience of violence is directly proportional to the duration and frequency of violent episodes. Overall, approximately one-third of the population risk for all mental illness is attributable to family violence [25].
Social
Control by the perpetrator who fears disclosure by the victim can lead to social isolation, prevention from paid employment or contact with medical practitioners.
Financial dependence and the responsibility of children increase isolation, loss of choices and difficulties of separation from the perpetrator. Poverty is prevalent and multifactorial. Separation from or incarceration of the perpetrator may lead to further loss of income.
Homelessness may be relative, where there is no sense of safety or security in the home, or absolute, where there is need for interim or emergency accommodation or families may be living on the streets. Children or elderly people living in violent circumstances may be institutionalized by authorities or carers.
Outcomes for male victims differ from female victims in several significant ways. Male victims typically express fewer feelings of fear and terror and less frequently feel trapped and controlled. Men are also generally less constrained by financial dependence. As fear, control, dependence and isolation contribute greatly to the psychological outcomes of family violence, women still suffer approximately 95% of the serious physical and psychological consequences of family violence [18].
Economic cost
The costs of family violence are vast. Costs include pain, suffering and premature mortality costs, health costs (victim, perpetrator and children), production-related costs (lost productivity), consumption-related costs (property replacement), second-generation costs (childcare, child protection), administrative (legal and forensic) and transfer costs (income support, lost taxes). The total annual cost of family violence in Australia in 2002–03 was AUD $8.1 billion. The lifetime cost per victim was AUD $224 470 [26]. The National Council to Reduce Violence Against Women and their Children has more recently projected that family violence will cost Australia $9.9 billion in the years 2021–22, if appropriate action is not taken [27]. International studies estimate costs in the billions of dollars annually [28].
Barriers to detection and reporting of family violence
Detection rates of family violence in EDs are low. Only 10% of those who present with acute family violence-related injuries or issues will be asked by the attending nurse or physician or volunteer information about the violence issue. Documentation of violence in the medical record is rare [9]. Barriers to detection may include system factors, such as inadequate privacy, health-practitioner’s lack of time and education, health-practitioner’s attitudes and cultural, social and gender issues.
Crime statistics in Australia show a general increase in reporting of family violence. Rates of women reporting physical and sexual assault to the police rose from 19% and 15% in 1996, respectively to 36% and 19%, respectively in 2005 [10,29].
A range of barriers can inhibit victims’ disclosure, including feelings of fear and shame, concerns about not being believed or about further victimization, anxiety about possible medical or legal processes, as well as familial, cultural or religious pressures. In some cases, individuals do not recognize themselves as victims of violence or may not have yet considered seeking assistance in respect to their violent partner.
Indigenous women in Australia report violence rarely. Historical interactions with police, such as forcible removal of children and high rates of Aboriginal death in custody, contribute to indigenous women fearing for the safety of themselves and their families when police or social services are involved [20] and the lack of accessible and culturally appropriate legal processes create further barriers to reporting. The elderly may be prevented from reporting by fear of further abuse, neglect or the threat of institutionalization [20].
Screening
The high prevalence of family violence, low positive predictive values of demographic factors and clinical presentations, low detection rates and high incidence of subsequent physical and psychological illness have supported the argument for universal screening. Opportunistic screening may increase detection rates of family violence. Detection rates without screening are in the order of 0.4%. Rates of detection rise to approximately 14% with the use of simple direct questioning [30]. The use of a single screening question may be as effective as asking several questions. Screening questions should be simple and direct such as ‘Do you feel safe at home?’ or ‘Are you afraid of your partner?’ Explanation that these questions are routine may improve patient comfort.
Screening may indicate to the victim that channels of communication are open and that help will be available. It educates women about violence, its nature and prevalence. Screening may also be important in detection of perpetrators. Approximately 40% of family violence perpetrators have sought medical attention in the preceding 6 months with half having attended an ED [31].
Most women find screening an acceptable practice, however, up to two-thirds of medical practitioners and 50% of nurses are not in favour of performing screening. Reported barriers include a lack of education on how to ask questions about abuse, language barriers, a personal or family history of abuse and time constraints [32]. In the USA, the legal implications of mandatory reporting add to reluctance to screen.
Screening may improve detection rates and referral rates to external agencies. However, currently, no evidence exists that screening leads to improved health outcomes for victims [33].
Management
The management of family violence is complex. Leaving a violent relationship is no guarantee of safety and may precipitate increased levels of violence. Leaving a violent relationship is a process and not an event and requires support through all phases. Help may best be offered by validating the disclosure, expressing concern, listening, providing support, ensuring safety and offering a bridge to services.
Understanding
Interviews with survivors of family violence provide a framework for understanding the stages through which a victim must work before leaving a violent relationship [34]. The pre-contemplative phase is where the victim is not consciously aware of or is in denial about the abuse. A contemplation phase follows where the abuse is acknowledged, but the victim is unable to decide to leave. A preparation stage follows where steps are taken in preparation to leave and take action. The action phase involves leaving the relationship but is typically characterized by episodes of return to the relationship. A maintenance phase occurs when a period of 6 months without return to the relationship has occurred.
Listening and understanding where the victim is in terms of progress through these phases assists in assessing readiness for change and guides intervention. The aim is to validate the person’s experience, emphasize that they did not deserve or cause the abuse and empower the making of independent decisions that lead to improvements in safety and well-being.
Referral
There are multiple agencies to assist victims of family violence. Community services include hotlines for emergency advice through to counselling services, emergency shelters, police and legal services.
Safety
Safety is paramount and emergency accommodation or hospital admission may be required to ensure immediate safety. Safety is an ongoing issue as the greatest risk of injury occurs while leaving the relationship. Seventy per cent of family violence homicides occur as the woman is leaving or has left the home [35]. Continued contact with the perpetrator due to custody arrangements make the risk of abuse a continuing one.
Reporting
Most Australian states and territories have not implemented mandatory reporting of family violence for adults. The exception is the Northern Territory, where mandatory reporting provisions were introduced in 2009. In contrast to adult victims of family violence, all Australian states and territories have some description of mandatory reporting of suspected cases of child abuse and neglect. Variations exist regarding which professionals are legally required to report, however, these generally include doctors, nurses and midwives. Most jurisdictions protect the identity of persons making a notification whether mandated or not.
Documentation
Documentation in the medical record may provide vital evidence and should be objective and accurate. Direct quotes and descriptions of behaviours and appearances increase objectivity. Body maps and photographs assist documentation of physical injury. Sexual assault examinations ideally should be performed by specially trained staff to ensure legal admissibility of evidence.
The management of family violence requires a coordinated response from all practitioners and service providers involved from when the victim first discloses the violence. This includes the health system, social services and the police and judicial system if the victim chooses to pursue this course of action. At all times, the victim’s wishes must be paramount and the service providers should do their utmost to support these wishes.
Conclusion
Family violence is a pervasive social problem that does not discriminate across age, cultural background, religion or socioeconomic status. The implications of family violence are substantial, including physical injury, mental illness, economic and social costs and fatal outcomes. Despite the commonness of family violence, it frequently remains undetected and unreported. Identification of risk factors for violence and interventions aimed at increased identification and referral can be considered in the ED environment. When violence is disclosed, the expression of concern and a willingness to listen, risk assessment, safety planning, support and stage-appropriate referral are the mainstays of management.
Controversies and future directions
While there has been considerable research on screening for family violence in emergency departments, further research regarding the outcomes after screening interventions is required to ensure efficacy and safety of screening.
Mandatory reporting of violence among adults remains controversial.
Management strategies should not be aimed at encouraging the woman immediately to leave the violent relationship. Risk assessment, safety planning, support and stage-appropriate referral are the mainstays of management.
References
1. Council of Australian Governments. The national plan to reduce violence against women and children 2010–2022. Canberra; 2010.
2. Mitchell L. Domestic violence in Australia – an overview of the issues Canberra: Department of Parliamentary Services; 2011.
3. Mouzos J, Makkai T. Women’s experience of male violence; findings from the Australian component of the International Violence Against Women Survey (IVAWS). In: Australian Institute of Criminology, (ed.). Research and Public Policy Series 56. Canberra; 2004.
4. Reid RJ, Bonomi AE, Rivara FP, et al. Intimate partner violence among men: prevalence, chronicity and health effects. Am J Prevent Med. 2008;34:478–485.
5. Duke A, Davidson M. Same-sex intimate partner violence: lesbian, gay and bisexual affirmative outreach and advocacy. J Aggress Maltreat Trauma. 2009;18:795–816.
6. Australian Domestic and Family Violence Clearinghouse. The impact of domestic violence on children: a literature review Sydney: Australian Domestic and Family Violence Clearinghouse; 2011.
7. Bates L, Redman S, Brown W, et al. Domestic violence experienced by women attending an accident and emergency department. Aust J Publ Hlth. 1995;19:293–299.
8. Roberts GL, O’Toole BI, Raphael B, et al. Prevalence study of domestic violence victims in an emergency department. Ann Emerg Med. 1996;27:741–753.
9. Abbott J, Johnson R, Koziol-McLain J, et al. Domestic violence against women Incidence and prevalence in an emergency department population. J Am Med Assoc. 1995;273:1763–1767.
10. Australian Bureau of Statistics. Personal Safety Survey, Australia, 2005 reissue Canberra: Australian Bureau of Statistics; 2006.
11. Virueda M, Payne J. Homicide in Australia: 2007–08 National Homicide Monitoring Program annual report. Canberra: Australian Institute of Criminology; 2010.
12. Koziol-McLain J, Webster D, McFarlane J, et al. Risk factors for femicide-suicide in abusive relationships: results from a multisite case control study. Violence Victims. 2006;21:3–21.
13. World Health Organization. Multi-country study on women’s health and domestic violence against women: initial results of prevalence, health outcomes and women’s responses Geneva: World Health Organization; 2010.
14. Gartland D, Hemphill SA, Hegarty K, et al. Intimate partner violence during pregnancy and the first year postpartum in an Australian pregnancy cohort study. Matern Child Hlth J. 2011;15:570–578.
15. Shorey RC, Febres J, Brasfield H, et al. The prevalence of mental health problems in men arrested for domestic violence. J Fam Violence. 2012;27:741–748.
16. Riggs DS, Caulfield MB, Street AE. Risk for domestic violence: Factors associated with perpetration and victimization. J Clin Psychol. 2000;58:1289–1316.
17. Roberts GL, Williams GM, Lawrence JM, et al. How does domestic violence affect women’s mental health? Women Hlth. 1998;28:117–129.
18. Frank JB, Rodowski MF. Review of psychological issues in victims of domestic violence seen in emergency settings. Emerg Med Clin N Am. 1999;17:657–677 vii.
19. Muelleman RL, Lenaghan PA, Pakieser RA. Battered women: injury locations and types. Ann Emerg Med. 1996;28:486–492.
20. Astbury J, Atkinson J, Duke JE, et al. The impact of domestic violence on individuals. Med J Aust. 2000;173:427–431.
21. McCloskey LA, Williams CM, Lichter E, et al. Abused women disclose partner interference with health care: an unrecognized form of battering. J Gen Intern Med. 2007;22:1067–1072.
22. Mouzos J, Rushforth C. Family homicide in Australia, no.255, Trends and Issues in Crime and Criminal Justice Canberra: Australian Institute of Criminology; 2003.
23. Wadman MC, Muelleman RL. Domestic violence homicides: ED use before victimization. Am J Emerg Med. 1999;17:689–691.
24. Shumaker DM, Prinz RJ. Children who murder: a review. Clin Child Fam Psychol Rev. 2000;3:97–115.
25. Roberts GL, Lawrence JM, Williams GM, et al. The impact of domestic violence on women’s mental health. Aust NZ J Publ Hlth. 1998;22:796–801.
26. Access Economics. The cost of domestic violence to the Australian economy. Canberra: Access Economics Pty Ltd; 2004.
27. National Council to Reduce Violence Against Women and their Children 2009. The cost of violence against women and their children. Department of Families, Housing, Community Services and Indigenous Affairs, Canberra; 2009.
28. Laing L. Economic costs of domestic violence: Australian Domestic and Family Violence Clearing House. University of New South Wales; 2002.
29. Australian Bureau of Statistics. Women’s Safety Australia 1996. Canberra; 1996.
30. Morrison LJ, Allan R, Grunfeld A. Improving the emergency department detection rate of domestic violence using direct questioning. J Emerg Med. 2000;19:117–124.
31. Coben JH, Friedman DI. Health care use by perpetrators of domestic violence. J Emerg Med. 2002;22:313–317.
32. Yonaka L, Yoder MK, Darrow JB, et al. Barriers to screening for domestic violence in the emergency department. J Contin Educ Nurs. 2007;38:37–45.
33. Ramsay J, Richardson J, Carter YH, et al. Should health professionals screen women for domestic violence? Systematic review. Br Med J. 2002;325:314.
34. Gerbert B, Caspers N, Bronstone A, et al. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med. 1999;131:578–584.
35. Haywood YC, Haile-Mariam T. Violence against women. Emerg Med Clin N Am. 1999;17:603–615 vi.
21.4 Alcohol-related illness
Ioana Vlad
Essentials
1 Acute alcohol intoxication and withdrawal are responsible for many emergency department attendances and carry significant morbidity and mortality.
2 Chronic gastrointestinal and hepatic disease, coagulopathy and secondary bleeding complications, confusional states, mental illness, central nervous system disease with neuropathy and immunosuppression are common in alcohol-dependent persons, with complications that increase the morbidity and mortality further.
3 Wernicke’s encephalopathy is an uncommon but serious illness related to vitamin B1 deficiency. It requires high-dose parenteral thiamine 500 mg IV tds.
4 Many serious illnesses mimic alcohol intoxication or are masked by it. Maintain a high index of suspicion in the intoxicated patient with an altered conscious state.
5 Emergency physicians are uniquely placed to screen for high-risk drinking and to offer brief advice or intervention to this group to reduce the burden of recurrent alcohol abuse.
Introduction
Alcohol-related illness is common across the world and has a high prevalence in emergency department (ED) presentations. Alcohol misuse not only places the individual at risk of acute intoxication and injury but also poses significant long-term health issues.
Acute alcohol intoxication causes much morbidity and mortality from all forms of violence from motor vehicle and other accidents, interpersonal to self-harm. Chronic alcohol use contributes to many hospitalizations and deaths due to alcohol-related medical conditions and brain injury, resulting in both physical and psychosocial impairment.
Many acutely intoxicated patients presenting with an altered conscious state have significant co-morbidities masked by alcohol, which must be considered on each presentation.
Emergency physicians should not only recognize and treat alcohol-related emergencies, but also intervene in patients at high risk from their alcohol intake who present with other conditions. Early opportunistic screening using recognized alcohol screening tools and standardized brief interventions reduce ‘at-risk’ drinking and the morbidity and mortality from alcohol-related illness.
Epidemiology
Australia ranks 30th of 180 countries for alcohol consumption per capita. Australian alcohol consumption per capita is estimated at 9.8 L of pure ethanol per person per annum [1]. The percentage of Australian drinkers who report consuming more than the National Health and Medical Research Council (NHMRC) recommended levels for preventing chronic harm is decreasing (10% in 2008 vs 44% in 2001); however, 35% of Australian drinkers still consume more than the recommended amount for preventing short-term harm [2]. Alcohol misuse, morbidity and mortality among indigenous Australians is appreciably higher than the non-indigenous; certain populations, such as in central Northern Territory and north Western Australia, experienced double the national alcohol-attributable death rate in 2004 [3]. Death rates attributable to alcohol are higher in rural than metropolitan areas. Deaths from acute alcohol-related causes are most common in younger people aged 15–29 years, but chronic alcohol-related deaths mostly occur in those over 45 years [1].
Alcohol use is implicated in more frequent attendance at EDs [4] with presentations most commonly due to acute intoxication and injuries sustained by violence or motor vehicle trauma. Alcohol consumption is an important reason for repeat ED attendance and is the most common reason for repeat use of an ambulance to attend EDs [5]. In one study, a core group of alcohol-related attendees accounted for 4.3% of ED presentations, but 28% of ambulance transports to ED, 70% of those transports being for episodes of acute intoxication [5].
Six per cent of young persons attending city hospital EDs are for alcohol-related reasons, with injury significantly more likely among alcohol users than illicit drug users [6]. Among young people attending the ED, nearly 38% may be drinking harmfully, 18% may have consumed alcohol in the previous 6 hours and 15% consider their attendance to be alcohol-related [7]. Up to 45% of injured patients attending ED may have consumed alcohol within the past 24 hours and almost 30% in the last 6 hours [8].
The natural history of alcohol dependence is to remit and relapse, with a relentless progression to early death. Risk factors for alcoholism are a family history of alcohol dependence or total abstention, parental divorce, youngest child, other substance misuse, availability of alcohol and extremes of income.
Pharmacology
Pharmacokinetics
Alcohol is passively absorbed from the entire gastrointestinal tract (GIT), with about 25% from the stomach. Absorption is rapid within 60–120 minutes of intake and may be slowed by food. Alcohol is distributed throughout body water; females and obese people with lower body water-to-fat ratio reach higher blood alcohol concentrations (BAC) sooner than lean counterparts. Hepatic oxidative metabolism occurs via alcohol dehydrogenase. Alcohol-tolerant people also utilize the hepatic microsomal ethanol oxidizing system, which is upregulated with increasing drinking. First-order elimination kinetics becomes saturated as the BAC increases, changing to zero-order kinetics and slower sobering at higher BAC.
Pharmacodynamics
Alcohol is thought to act on γ-aminobutyric acid A (GABAA) inhibitory neuroreceptors in the brain causing central nervous system (CNS) depression. The characteristic euphoria is thought related to the release of endogenous opioids (endorphins). Rapidly rising BAC causes quicker and more pronounced behavioural changes than the same level achieved over hours. A steady state of absorption to metabolism and excretion can be achieved at about one standard drink per hour. A standard drink is defined as containing 10 g or 12.5 mL of pure alcohol. Behavioural intoxication depends on factors such as habituation, food co-ingestion, body habitus and the concentration of alcohol in the drink.
Measurement of blood alcohol concentration
The blood alcohol concentration may be estimated using a portable breathalyser that estimates BAC after measuring alcohol concentration of alveolar air. This is a useful non-invasive screening tool but relies on a cooperative and awake patient being able to exhale adequately for the reading. There is an approximate difference of 15–20% between breath alcohol readings and serum BAC. Readings are influenced by temperature, hyper- or hypoventilation prior to exhalation, haematocrit level, other substances, such as ketones, and machine error. Directly measured serum blood alcohol concentration is more reliable. The Australian legal limit for driving is 0.05%; in New Zealand it is 0.04%, while in the USA and UK it is 0.08%.
Chronic alcohol-related illness
Gastrointestinal
Chronic alcohol use results in disease of the gastrointestinal tract (GIT), liver and pancreas. Morbidity most frequently arises from GIT bleeding, liver disease and pancreatopathy.
Gastrointestinal bleeding
The most common causes of alcohol-related GIT haemorrhage are peptic ulcer disease (PUD) and the consequences of portal hypertension, such as oesophagogastric varices or subepithelial gastropathy. Mallory–Weiss tears, oesophagitis and alcoholic gastropathy are less frequent causes of alcohol-related GIT haemorrhage. Heavy alcohol use may be a risk factor for development of PUD, although the exact pathogenesis is poorly understood and the role of alcohol may be additive to the effects of Helicobacter pylori, non-steroidal anti-inflammatory drugs (NSAIDs) and tobacco [9].
Variceal bleeding in portal hypertension results from raised portal blood flow and portal vascular resistance due to hepatic fibrosis. Fifty per cent of cirrhotic patients develop varices and, once present, variceal bleeding occurs in 10–30% per annum. Variceal bleeding may be catastrophic with a 30% mortality for a first bleed. The 5-year survival was estimated at 26% in one patient series of variceal bleeding, of which 80% were alcohol dependent [10].
While Mallory–Weiss tears are less common, up to 44% are associated with alcohol use and may have significant morbidity due to blood loss [11]. Alcohol-induced vomiting against a closed glottis can also result in oesophageal rupture (Boerhaave’s syndrome).
Management of GIT bleeding
Close attention to airway, breathing and circulation is the first priority. Aggressive initial fluid resuscitation is necessary in shock with an initial crystalloid bolus of 500–1000 mL, followed by transfusion of blood products if required. Vitamin K 10 mg IV is indicated in patients with known or suspected liver cell failure. Replacement of clotting factors with factor concentrate or fresh frozen plasma and platelets will also be required if the patient requires massive transfusion or has abnormal coagulation secondary to chronic liver disease or to major haemorrhage [12].
An intravenous proton pump inhibitor, such as omeprazole 80 mg stat, followed by an infusion at 8 mg/h is often initiated for bleeding from presumed PUD, oesophagitis, gastritis or duodenitis. This decreases hospital length of stay and the need for endoscopic therapy but does not reduce transfusion requirement, re-bleeding, the need for surgery or death at 30 days [13].
Variceal bleeding
After the initial resuscitation and replacement of clotting factors if needed, acute variceal bleeding should be managed with a bolus of octreotide or terlipressin, followed by an infusion, while urgent upper gastrointestinal endoscopy is arranged. Terlipressin is a synthetic analogue of vasopressin, that reduces splanchnic blood flow and portal pressure. It is the only agent that has been shown to improve mortality (34% relative risk reduction) in the setting of acute variceal bleeding [14]. Octreotide is a synthetic somatostatin analogue that reduces splanchnic blood flow. Endoscopy is diagnostic for the site of bleeding, as well as being both therapeutic and prognostic. Therapy is usually by banding ligation, sclerotherapy or tissue adhesive. Sclerotherapy with the injection of varices with sclerosant with octreotide is more effective than sclerotherapy alone at controlling bleeding but may not improve longer-term mortality. Gastroesophageal balloon tamponade with Sengstaken–Blakemore or Minnesota tube can provide temporary haemostasis when sclerotherapy is not available or is unsuccessful. It controls bleeding in up to 80% of cases, but it does not affect long-term mortality and it is associated with a high rate of complications, especially if it is performed by individuals who are not familiar with its use [15].
Early variceal surgery by oesophageal transection or selective portocaval shunt or interventional radiology, such as transjugular intrahepatic portosystemic shunting (TIPSS), may enhance short- and long-term survival, but both techniques are complicated by the risk of encephalopathy. TIPSS is preferred if liver transplantation is being considered. When the acute episode of variceal bleeding is over, oral propranolol and isosorbide mononitrate are used as maintenance therapy for portal hypertension.
Alcoholic liver disease
Alcoholic liver disease (ALD) comprises a spectrum of disorders from alcoholic fatty liver (steatosis), inflammation (hepatitis) to progressive fibrosis (cirrhosis) and hepatoma. These occur from chronic insult to the liver due to oxidative stress, damage from free radicals and the immunogenicity of alcohol metabolites. Many factors are involved in the aetiology of ALD, including genetic predisposition, gender, ethnicity, nutrition, obesity and co-existent chronic viral hepatitis, non-alcoholic fatty liver and other liver diseases, such as autoimmune.
The duration and amount of alcohol consumed play important roles; drinking at levels above the NHMRC recommendations (more than two standard drinks a day, both in men and women) is a defined risk for the development of alcohol-related injuries, ALD and eventual cirrhosis. NHMRC also recommend drinking less than 4 standard drinks per occasion to reduce the short-term adverse effects of alcohol use, in particular alcohol-related injuries. Alcohol dependence does not inevitably lead to cirrhosis, as only 10–20% of heavy drinkers progress [16]. Alcoholic fatty liver is a common finding among alcohol-dependent patients but is not a frequent cause for presentation to an ED.
Alcoholic hepatitis and cirrhosis
Alcoholic hepatitis may present as acute anorexia, nausea, vomiting, right upper quadrant pain and jaundice. Treatment is supportive and abstinence from alcohol is essential (see Chapter 9.6).
Cirrhosis typically presents late, with subtle malaise, anorexia, weight loss, weakness and fatigue, with a combination of liver cell failure and the development of portal hypertension. Acute decompensation results in symptomatic ascites, jaundice, pruritus, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, variceal bleeding and coagulopathy.
Ascites
Ascites due to hypoalbuminaemia, secondary hyperaldosteronism and portal hypertension is usually recurrent. Sudden exacerbations may be caused by SBP, the development of portal vein thrombosis, a hepatoma or medication non-compliance. Symptoms include abdominal discomfort, girth increase and anorexia. Fever, chills and abdominal pain occur with SBP or, conversely, signs of sepsis are minimal but there is sudden worsening of jaundice or encephalopathy.
The long-term treatment of ascites includes sodium restriction and diuretics, especially spironolactone and/or furosemide. Problematic ascites may require fluid restriction, recurrent abdominal paracentesis and albumin transfusion. It is important to exclude SBP by paracentesis and polymorphonuclear (PMN) cell count, with greater than 250 PMN cells/mm2 being diagnostic. The treatment of SBP includes intravenous broad-spectrum antibiotics, such as ceftriaxone 1 g IV daily or timentin 3.1 g 6-hourly daily, followed by oral antibiotic prophylaxis with trimethoprim 160 mg and sulphamethoxazole 800 mg tablets once daily.
Coagulopathy and encephalopathy
Coagulopathy results from the failure of hepatic synthesis of coagulation factors, thus administration of vitamin K 10 mg IV and factor concentrate or fresh-frozen plasma is required in the bleeding cirrhotic patient. GIT bleeding may also precipitate hepatic encephalopathy, with confusion and characteristic asterixis. This potentially reversible decrease in neuropsychiatric function must be distinguished from other causes of an altered conscious level in the cirrhotic patient.
Hepatic encephalopathy is associated with an increased nitrogenous GIT load (such as from a gastrointestinal bleed), dehydration, sepsis, certain drugs, hyponatraemia or hypokalaemia, worsening liver function and increasing jaundice. The treatment includes supportive care, GIT cleansing with lactulose (oral and enema) and oral non-absorbable antibiotics, such as neomycin to reduce bacterial counts, although their efficacy is unclear [16].
Thrombocytopaenia
Thrombocytopaenia is a common finding in alcoholic liver disease and several factors contribute. The aetiology is multifactorial: direct toxicity of the alcohol on the bone marrow, portal hypertension and platelet sequestration in the enlarged spleen, decreased thrombopoietin (TPO) synthesis in the liver, with subsequent reduction in the proliferation and differentiation of megakaryocytes and platelet formation.
Alcoholic pancreatopathy
Alcoholic pancreatopathy is used to describe a group of pancreatic diseases caused by chronic heavy alcohol intake. It includes acute alcoholic pancreatitis, recurrent abdominal pain or GIT symptoms induced by alcohol, high serum levels of pancreatic enzymes or an abnormal pancreatic ultrasound. Recurrent bouts of acute alcoholic pancreatitis precede the development of pancreatic pseudocysts, chronic pancreatitis and pancreatic malignancies.
Alcohol is the most common aetiology of chronic pancreatitis (70–80%), although as few as 10% of heavy drinkers will develop it. Like cirrhosis, its aetiology is multifactorial; other risk factors include tobacco smoking and hyperlipidaemia, which should be addressed if early signs of pancreatopathy are recognized. Acute and chronic alcoholic pancreatitis are managed conservatively, with abstinence from alcohol, intravenous fluids, parenteral analgesia and antibiotics if pancreatic necrosis or an abscess are suspected (see Chapter 7.9).
Chronic pancreatitis can be debilitating with recurrent cycles of pain and admissions to hospital. Progressive pancreatic calcification, failure of exocrine and endocrine function and chronic pain can all be mitigated if alcohol is avoided. Recurrent pancreatic insults and chronic pancreatitis increase the risk of pancreatic carcinoma by up to 16 times.
Mental health and mental state issues
Depression and suicidal intent
Alcohol is a recognized risk factor for suicide. Mood expression and self-harm intent are often underestimated in the ED intoxicated patient. A Scandinavian study showed that 62% of 1207 ‘parasuicides’ who presented to an ED involved alcohol use, with even higher rates in young males. Psychiatric referral was less likely if alcohol was involved yet, after 5.6 years, 3.3% had completed suicide. This represented a 51-fold increased risk compared to the general population, with the risk of completed suicide being greatest in the first year [17].
Alcoholic hallucinosis
Alcohol misuse causes psychotic symptoms by several mechanisms, including direct intoxication, alcohol withdrawal, delirium tremens (DTs), Wernicke’s encephalopathy, Korsakoff psychosis and alcoholic dementia. Alcohol dependence doubles the risk of psychotic symptoms.
Alcoholic hallucinosis is a schizophrenia-like syndrome that differs from the other causes in that it occurs at a younger age, in a setting of clear consciousness and not related to acute withdrawal. There are no associated physical symptoms of autonomic dysfunction as in the DTs and its duration is longer with predominantly auditory hallucinations as opposed to visual. Its chronicity and derogatory auditory hallucinations are similar to schizophrenia, but thought disorder is not a feature.
Alcohol withdrawal states
The alcohol withdrawal syndrome follows prior alcohol dependence. Its clinical importance lies in the potential severity of the symptoms and signs, the need to consider alternative or concomitant pathology and the likelihood of seizures occurring. The principal symptoms are tremor, agitation, nausea and vomiting, sweating, anxiety and autonomic nervous system overactivity with tachycardia, tachypnoea and fever. Sleep disturbance, hallucinations and generalized tonic–clonic seizures generally begin within 10 hours of reduced alcohol intake, with a peak intensity by day 2. The withdrawal syndrome may occur in an individual who usually drinks an ‘eye opener’ or ‘hair of the dog’ but is prevented from doing so.
Alcohol withdrawal scales
A number of scales measure alcohol withdrawal. One simple one is to rate symptoms as mild (tremulousness), moderate (agitation) and severe (confusion). Most EDs use an alcohol withdrawal scale (AWS) to measure symptoms and predict likelihood of seizure and direct preventative management. The most commonly used AWS is the Clinical Institute withdrawal assessment – alcohol, revised scale (CIWA-R). This scale measures 10 items and was primarily developed for planned detoxification or for use on general medical and psychiatric wards [18]. Surprisingly, blood pressure and pulse, although often abnormal, are not included in the scale. A modified version that includes seizures in the AWS is also used [19]. Patients with high scores have an increased risk of seizure if they remain untreated. The higher the score, the greater the relative risk. However, some patients experience complicated withdrawal despite initial low scores.
Pharmacological therapy
Benzodiazepine (BZD) therapy reduces signs and symptoms of alcohol withdrawal and prevents complications [20]. All BZDs appear to have similar efficacy. Longer-acting agents, such as diazepam used with symptom-triggered dosing (as opposed to regular), decrease the total of drugs given and both shorten and smooth the clinical course. Early treatment is preferred to waiting for advanced withdrawal.
Published data on ideal doses are lacking. High-dose oral diazepam 20 mg 1- to 2-hourly may be needed for symptom control and up to 160 mg per day may be required to allow for BZD tolerance, which is common in alcohol-dependent patients. Under-dosing for fear of over-sedation is common.
Antipsychotics such as droperidol, haloperidol or olanzapine are commonly used to manage the agitation and other behavioural disturbances induced by severe alcohol withdrawal. However, they lower the seizure threshold and can cause anticholinergic syndrome if given in excessive doses. They can also cause prolongation of the QT interval and increase the risk of torsade de pointes in the alcoholic patients who are often hypokalaemic, hypocalcaemic and hypomagnesaemic. Carbemazepine is used in Europe and appears as effective as fixed-dose BZDs. β-Blockers decrease tremulousness but may worsen delirium and are not anticonvulsant. Clonidine improves symptoms of withdrawal but is not anticonvulsant. Vigabatrin has shown promise in reducing sedation, BZD use and the total withdrawal treatment time. Ethanol, of course, would ‘treat’ the symptoms of withdrawal.
Alcohol withdrawal seizures
Around 3–5% of those with severe alcohol use disorder experience withdrawal seizures within 48 hours of stopping drinking and 15% will have a seizure in their lifetime. Previous withdrawal seizure is the strongest predictor of recurrent seizure. Most alcohol withdrawal seizures are short lived and self-terminating. Localizing signs or prolonged seizure should prompt a search for alternate pathology. Intravenous BZD, such as midazolam 0.1–0.2 mg/kg, is given for prolonged seizure. Phenytoin is not recommended for alcohol withdrawal seizures, unless there is coexistent epileptic disorder.
Delirium tremens
DTs is characterized by confusion, altered conscious state and autonomic hyperactivity. The incidence of DTs has been reduced by effective early management of withdrawal and excluding intercurrent illness. DTs occur in less than 1% during any single withdrawal episode. The diagnosis is important, as the mortality approaches 15% if untreated. As symptoms usually manifest within 48 hours, DTs may be encountered in EDs experiencing access block or in short-stay observation units.
Risk factors for DTs: five risk factors are associated with the development of the DTs [21]. These include current infection, tachycardia greater than 120 beats/min, signs of alcohol withdrawal accompanied by BAC of more than 0.1%, seizure history and history of delirious episodes. DTs are rare in the absence of these factors. The treatment includes management in an intensive care with regular intravenous BZD, such as midazolam 0.1–0.2 mg/kg, and a search for underlying conditions, such as sepsis.
Wernicke’s encephalopathy
The classical features of Wernicke’s encephalopathy are ataxia, confusion and ophthalmoplegia, usually lateral rectus palsy. It is caused by thiamine deficiency, but severe deficiency may be present without these signs. In alcohol- dependent persons, oral thiamine absorption is poor. Malabsorption, reduced storage and impaired utilization of thiamine increase the risk of Wernicke’s encephalopathy.
Post-mortem studies suggest that thiamine deficiency sufficient to cause irreversible brain damage remains undiagnosed ante-mortem in 80–90% of alcohol-dependent persons. Wernicke’s encephalopathy should be considered in all patients in coma, as replacement of depleted brain thiamine is necessary. The mortality approaches 20% if left untreated.
Treatment of Wernicke’s encephalopathy
High-dose oral thiamine may be ineffective, thus parenteral therapy with thiamine 500 mg IV tds is recommended for at least 5 days. The risk of anaphylaxis is low with the current drug formulations [22,23]. The recommended prophylactic thiamine dosage has been increased to 200 mg parenterally tds.
Other alcohol-related neurological problems
Alcohol is a neurotoxin and chronic heavy use causes CNS damage, peripheral neuropathy, myopathy and movement disorders such as tremor, Parkinsonism, dyskinesias, cerebellar ataxia and asterixis.
Peripheral neuropathy
Peripheral neuropathy is common in alcohol misuse and has multiple aetiologies, including direct toxic effect of ethanol and malnutrition with thiamine defficiency. The prevalence among chronic drinkers is unclear but is estimated at between 9 and 50%. Other contributing factors are increased age, total lifetime dose of alcohol, nutritional status (malnutrition and thiamine deficiency) and family history of alcohol misuse. Alcoholic peripheral neuropathy is most commonly sensory in the lower limbs.
Alcoholic autonomic neuropathy
Alcoholic autonomic neuropathy is uncommon. It is often asymptomatic or causes erectile dysfunction in males, postural hypotension and/or diarrhoea. It is related to different pathological processes than sensory peripheral neuropathy.
Ataxia
Ataxia is a common presenting symptom and sign and may be due to peripheral neuropathy affecting proprioception, cerebellar degeneration or a combination of both. Cerebellar ataxia is possibly an extension of the insult from thiamine deficiency as in Wernicke’s encephalopathy. Whereas in Wernicke’s encephalopathy the ataxia may be reversible by thiamine administration, full recovery is rare and permanent damage occurs affecting the superior cerebellar vermis.
Blackouts
Neuronal failure resulting in blackouts and amnesia is a direct toxic result of alcohol on the CNS. This is especially common in binge drinkers. Orthostatic hypotension from autonomic failure is differentiated on the clear relationship to posture.
Respiratory illness in alcohol-dependent persons
Chronic obstructive airways disease
Chronic obstructive airways disease (COAD) is common among alcohol-dependent persons, mostly due to the high prevalence of concurrent tobacco smoking (see Chapter 6.5).
Pneumonia
Alcohol dependence increases the risk of community-acquired pneumonia due to immunosuppression, as well as general lifestyle factors, such as hygiene and smoking. Typical organisms include Streptococcus pneumoniae and Haemophilus influenzae. There is also a higher frequency of cavitating disease, empyema and unusual pathogens. Anaerobic and Gram-negative organisms are frequent colonizers of the oropharynx and GIT and aspiration pneumonia is common. Opportunistic disease, such as tuberculosis, Pneumocystis carinii pneumonia, now known as Pneumocystis jiroveci, and Legionella are also more frequent in alcohol-dependent persons.
Metabolic problems with alcohol use
Alcohol use and metabolic acidosis
Alcoholic ketoacidosis
There is contention about the existence and frequency of alcoholic ketoacidosis. This refers to high anion-gap metabolic acidosis associated with the acute cessation of alcohol on a background of chronic alcohol abuse and relative starvation. Clinical features include nausea, vomiting, abdominal pain, tachycardia, tachypnoea and hypotension, all of which may occur in other alcohol-related emergency presentations.
Chronic alcohol intake can lead to depleted carbohydrate and protein stores in the body due to relative starvation. Reduced hepatic gluconeogenesis from substrates, such as lactic acid, glycerol and amino acids, can cause hypoglycaemia. In dehydrated states, the combination of hypotension and hypoglycaemia results in reduced insulin production and raised catecholamines, cortisol, glucagon and growth hormone. These hormones promote utilization of fatty acids for energy, resulting in ketogenesis.
Alcoholic ketoacidosis has been described as ‘a common reason for investigation and admission of alcohol-dependent patients’, although research data appear limited. There may be an increased frequency of sudden death among patients who present in this fashion [24].
Diabetic ketoacidosis
Acute alcohol intoxication can precipitate ketoacidosis in known insulin-dependent diabetics.
Acute alcohol ingestion can cause a state of acute insulin resistance. Alcohol-induced post-prandial hyperinsulinaemia occurs without significant decrease in blood glucose levels, consistent with impaired insulin sensitivity. Relative starvation may result in hypoglycaemia and reduced insulin release. Alcohol-induced insulin resistance is important in these patients to recover from hypoglycaemia. Conversely, there is a reduced risk of type II diabetes mellitus in moderate drinkers (18–48 g per day) compared to light or heavy drinkers.
Other metabolic acidosis
Metabolic acidosis is rare in alcohol intoxication alone. One study of 60 ED patients with BAC greater than 0.1% described seven patients with a raised serum lactate, all of whom had alternative reasons for this, such as seizure, hypoxia and sepsis [25]. The treatment of an alcohol-dependent patient with metabolic acidosis is symptomatic with intravenous crystalloid fluid resuscitation and rehydration, thiamine 200 mg IV, 5% or 10% dextrose for hypoglycaemia, electrolyte replacement (see below) and a search for and treatment of another underlying cause, such as sepsis.
Electrolyte disturbance
There are no direct correlations between acute or chronic use of alcohol with specific electrolyte disorders, although certain deficiencies are characteristic, such as hypokalaemia, hyponatraemia, hypomagnesaemia, hypophosphataemia and hypocalcaemia. The causes include poor intake, malabsorption, excessive losses from vomiting, diarrhoea and fluid diuresis, reduced renal tubular reabsorption and dilutional changes due to polydipsia.
Electrolyte imbalances result in disturbance of other endocrine systems. Thus, hypomagnesaemia suppresses parathyroid hormone release, resulting in hypocalcaemia. Electrolyte disturbances are also related to alcohol-induced illness, such as pancreatitis or pneumonia.
Cardiovascular
Coronary heart disease
There is a reduced mortality from coronary heart disease in diabetic moderate drinkers (approximately 28 g per day). However, alcohol use in diabetes increases the risk of retinopathy, peripheral neuropathy and foot ulcers. Coronary protective effects of alcohol are due to influences on increased high-density lipoprotein (HDL) cholesterol, platelet function and fibrinogen.
Hypertension
Acute alcohol intake is a vasodilator, whereas drinking alcohol over the longer term causes systolic hypertension and increased aortic stiffness. An assessment by the World Health Organization Global Burden of Disease 2000 Comparative Risk Analysis attributed 16% of all hypertensive disease to alcohol intake. These findings may be confounded by other lifestyle factors and there are many contrasting effects of alcohol at various intakes, depending on gender and body mass index (BMI). Thus, raising HDL cholesterol is cardioprotective, but developing central obesity ‘beer gut’ is not. Overall, any benefits of moderate alcohol consumption on coronary disease are likely to be outweighed by harmful effects.
Cardiac arrhythmias
Heavy alcohol use is associated with an increased risk of sudden cardiac death, most commonly due to ventricular arrhythmias. Atrial arrhythmias including atrial fibrillation occur commonly after heavy binge drinking, ‘holiday heart’, in both acute and chronic drinkers. They are not necessarily associated with cardiomyopathy. The risk of a cardiac arrhythmia is increased by electrolyte abnormalities, such as hypokalaemia, hypomagnesaemia and hypocalcaemia.
The treatment of arrhythmias is as recommended by the current Advanced Cardiovascular Life Support guidelines.
Cardiomyopathy
Concentric left ventricular hypertrophy is common in chronic alcohol users. Dilated cardiomyopathy may ensue with progressive dilatation and fibrosis, leading to congestive cardiac failure. This myotoxic process has a worse prognosis than idiopathic dilated cardiomyopathy, particularly if drinking continues. Myocyte function can improve with total abstention.
Aggressive anti-failure therapy should be implemented with dietary measures, such as reduced sodium intake, an angiotensin converting-enzyme inhibitor and other pharmacotherapy, even if total abstention cannot be achieved.
The so-called ‘wet beri-beri’ cardiomyopathy is caused by severe thiamine deficiency that leads to myocardial dysfunction and peripheral vasodilation. Thiamine absorption is impaired by alcohol and long-term use of frusemide depletes the body of water-soluble vitamins, including thiamine. Changes in myocardial function occur within 1 hour of starting parenteral thiamine therapy and are back to normal within 1 week of treatment [26].
Malignancy
Alcohol has been causally linked to many types of neoplasia, most commonly those of the GIT. Oropharyngeal and other head and neck cancers have a direct link to alcohol. Drinking more than 1.5 bottles of wine daily elevates the risk of oesophageal cancer 100 times. Hepatocellular carcinoma (HCC) is usually preceded by alcoholic cirrhosis in the Western world, although other causes include hepatitis B and C viruses. Progression of cirrhosis to HCC is more rapid if drinking continues. Chronic alcohol consumption is also related to laryngeal, breast, pancreatic and colorectal carcinomas.
Important illnesses to be excluded that mimic alcohol intoxication
It is hard to know when to look for another cause for altered conscious state in the habitual drinker or intoxicated person, as many alternative conditions must be considered that mimic apparent alcohol intoxication (Table 21.4.1). The mean length of altered conscious state in an ED for intoxication alone has been reported at 3.2 hours with a wide standard deviation of 3.6 hours, with the likelihood of another pathology being present increasing rapidly after 4 hours. Close observation looking for trends in autonomic responses and neurological signs and detailed examination looking for other pathology are more appropriate than waiting for, or intervening after, a certain period of time.
Table 21.4.1
Illnesses not to be missed in the presumed intoxicated person
CNS: central nervous system; GHB: γ-hydroxybutyrate; BZD: benzodiazepine; UTI: urinary tract infection.
Metabolic disturbance
There is little evidence that hypoglycaemia occurs in adults with simple alcohol intoxication alone; with one large study of ED patients screened for alcohol use and serum blood glucose finding no linear relation between blood alcohol and glucose levels. The incidence of hypoglycaemia is not increased in alcohol- related ED attendances compared to sober patients. Intravenous glucose administration has not been shown to be useful in changing rates of alcohol elimination or decreasing periods of intoxication. However, it is essential in each patient with an altered mental state to measure the blood glucose and treat if it is low. Chronic alcoholics have limited hepatic glycogen stores due to malnutrition, so administering glucagon is not effective as it cannot initiate gluconeogenesis. In the intoxicated or alcohol-dependent patient, an alternative cause for hypoglycaemia should still be sought.
Hyponatraemia may occur with sepsis and general debility. Diabetic ketoacidosis or hyperglycaemic, hyperosmolar non-ketotic syndrome should also be excluded (see Chapter 11.2).
Head injury
Head injuries are not only more common in intoxicated and alcohol-dependent patients, they are easily missed due to a presumption that intoxication is the main cause of the altered conscious state. Head injuries may be complicated by coexisting coagulopathy and thrombocytopaenia from liver disease, cerebral atrophy and underlying metabolic problems. A computed tomography (CT) brain scan is essential to rule out intracranial pathology, particularly cerebral contusion, extradural haematoma, subdural haematoma and base of skull fracture.
Close neurological observation in a monitored resuscitation area is necessary in the intoxicated person with an altered conscious level and a possible head injury. Worsening confusion, deteriorating level of consciousness or focal neurology necessitate an urgent CT brain scan, which may be challenging in a poorly compliant patient. Intravenous sedation or even endotracheal intubation may be necessary to obtain a CT scan safely.
Other intracranial pathology
Altered conscious state: differential diagnosis
A patient with any significant intracranial pathology may present with an altered conscious state mimicking alcohol intoxication. The chronic alcohol-dependent patient may present with an unusual cerebral infection, such as cryptococcal meningitis, cerebral abscess or herpes encephalitis. Also a cerebrovascular accident, either embolic or haemorrhagic, is more likely in the habitual drinker, due to co-morbid vascular disease and smoking, hypertension and coagulopathy.
An altered conscious state may be due to a seizure from alcohol excess or withdrawal, status epilepticus or a post-ictal state. Cerebral neoplasia, particularly metastases, may present late in this population. Again a CT scan is usually indicated in the alcohol-dependent patient following a seizure, particularly if there is persisting or deteriorating confusion or focal neurology. A lumbar puncture may be needed to exclude meningitis or a subarachnoid haemorrhage if there is clinical suspicion, even if the CT brain scan was normal.
Other toxicological states in the alcohol-dependent patient
Multiple drug ingestion
Multiple drug ingestion, whether prescription or illicit, is common in regular drinkers for recreational reasons, due to dependence, to ‘come down’ from other drug effects, in accidental overdose or in deliberate self-harm. The most common and important ingested drugs to consider include BZDs, opiates, paracetamol, often as over-the-counter analgesics, antidepressants including tricyclics and selective serotonin reuptake inhibitors, γ-hydroxybutyrate, ecstasy and other sympathomimetics, such as cocaine and ketamine.
Other alcohols
Other alcohols, such as methanol, ethylene glycol and isopropyl alcohol, although rare, should be considered in the significantly intoxicated, self-harm patient. ‘Methylated spirits’ bought over the counter in Australia only contains 95% ethanol v/w with no methanol at all and, in New Zealand, the methanol content has been reduced to 2% or less, due to deaths attributed to chronic misuse and methanol poisoning there.
Serum drug levels
The only clinically useful screening serum drug levels are paracetamol and ethanol. Other drug levels take hours to days to perform (institution dependent); thus they are not of use at the time and should only be requested if there are specific indications. The only safe antidotes to consider are naloxone, thiamine and glucose. Flumazenil is not recommended due to the risk of inducing seizures and then not being able to manage them effectively.
Other sepsis
Sepsis must be considered in any person with an altered conscious state potentially masked by alcohol intoxication and a directed septic work-up carried out.
Treatment of alcohol-related illness
Alcohol intoxication
Intoxication starts with a feeling of well-being and an increasing sense of relaxation, followed by impairment of judgement and incoordination. At BAC of 0.1%, dysarthria, ataxia and disinhibition are common. At BAC of 0.2%, confusion occurs and new memories are not formed. At BAC of 0.25%, cortical depression is seen with the onset of stupor. At BAC of 0.4%, most are unconscious and at risk of respiratory depression and death. The mean BAC found in fatal alcohol intoxication is 0.45%.
‘Pathological intoxication’
Some people have idiosyncratic responses to alcohol, the so-called ‘pathological intoxication’, which is more common among certain ethnic groups. A clear indicator of alcohol tolerance and neuroadaptation is the recording of high BAC in a person functioning at an otherwise reasonable level, for example the patient capable of normal conversation and gait with a BAC 0.3%. This may follow a continuous prolonged drinking binge.
Treatment of the acutely intoxicated person
The treatment of an acutely intoxicated person is supportive, protecting the at-risk airway and placing in the semi-prone position to reduce the risk of gastric aspiration. Gastric emptying procedures are not recommended under any circumstances. Intravenous fluids in simple alcohol intoxication do not increase the elimination or decrease the BAC. Likewise, IV 5% dextrose administration has not been shown to be useful in changing the rates of alcohol elimination or decreasing periods of intoxication.
There remains no antidote to alcohol intoxication. As alcohol affects endogenous opiate GABA receptors, both naloxone and flumazenil have been tried with no effect. Flumazenil use in the alcohol-intoxicated patient is dangerous as it renders benzodiazepines ineffective in the treatment of seizures for about 45 minutes after its use. It can also precipitate seizures if the patient is a chronic benzodiazepine user. Various substances have been tried in animals, but none so far is safe and/or effective. There has been interest in pyridoxine and, more recently, its analogue metadoxine in hastening alcohol metabolism and reversing both the biochemical and the clinical symptoms of intoxication, but studies are small [27].
‘Hangover’
It was estimated in the UK in 2003 that £2 billion in lost work value was due to post-alcohol-related headache and malaise ‘hangover’, which may be a greater economic problem than habitual intoxication. Paradoxically, light or binge drinkers’ hangovers cause the most lost work time as the hangover is more common and the sufferer is more commonly in regular employment than the heavy drinker.
Diagnosis and management
A hangover is distinguished from the alcohol withdrawal syndrome as it follows a defined single episode of intoxication. Symptoms include headache, feeling generally unwell, diarrhoea, anorexia, nausea, tremulousness and fatigue. The presence of two or more of these symptoms following alcohol intake has been used to define a hangover [27]. Acetaldehyde, the dehydrogenated metabolite of alcohol, has been implicated. Alcohol alters cytokine production and thromboxane B2 is increased, an effect blocked by prostaglandin inhibitors. This may explain why prostaglandin inhibitors, such as NSAIDs, including aspirin, may have some limited prophylactic effect on hangover development.
Hangover is not solely dose related. Hangovers are worse with dehydration, no food intake, decreased sleep, increased physical activity while intoxicated and poor general physical condition. Congener byproducts of some alcohols including aldehydes, esters, histamine, phenols, tannins, iron, lead and cobalt are found, especially in darker liquors, which are associated with an increased severity and incidence of hangover. Clear liquors, such as gin, vodka and rum, may lead to fewer hangovers. The evidence for hangover treatment and prevention is minimal [28,29].
The habitual alcohol-dependent emergency attender
Most EDs, particularly in metropolitan areas, have a group of recurrent ED attenders who keep presenting with alcohol intoxication and chronic alcohol-rela ted disease. Such people are usually male, aged 30–40 years and often have no fixed place of abode. They usually are well known to neighbouring EDs, community services and police. They tend to attend in cycles and an absence of attendance may indicate a prison term, a medical illness and/or hospital admission, an attempt at sobriety, use of an adjacent ED or sudden death. Over a year they may accumulate multiple investigations, especially CT scans of the head. This group has an increased mortality over time from assault and other trauma, as well as alcohol-related illness associated with neglect.
The ED as a temporary refuge
The ED provides a temporary refuge in an otherwise chaotic lifestyle and an opportunity for a health assessment and intervention. It is important to realize that providing care for this group of people is core business for every ED, despite any frustrations felt. Interventions to alter lifestyle and prevent recurrent attendances are successful. ED initiated case management involving community linkages and assistance with accommodation improves health outcomes but may increase ED utilization. Serial inebriate programmes may target this group, often commencing with socialization skills, such as personal hygiene and nutrition management [30]. Acceptance to such programmes is often precipitated by the threat of imprisonment. Such programmes have been demonstrated to be cost-effective.
Assessment of alcohol misuse
Alcohol screening tools
Emergency physicians witness daily the effects of lifestyle abuse on ED presentations and thus may find many opportunities to intervene opportunistically to affect the long-term health of the patient, as well as treating the immediate presentation. This is particularly valuable for patients with irregular contact with other medical services, such as the itinerant and the homeless [31].
Screening for chronic alcohol abuse or dependence
Any screening tool to be of value must have adequate sensitivity and specificity for detecting the illness involved and there should be an effective, cost-effective intervention available. Many screening tools for chronic alcohol abuse or dependence have been developed for primary care, with the best known being the CAGE questionnaire [32]. This poses four questions on behaviour and a positive answer to two or more indicates probable chronic alcohol abuse (Table 21.4.2).
Table 21.4.2
CAGE screening questionnaire for alcohol abuse
C=‘Have you ever felt you should Cut down on your drinking?’
A=‘Have people Annoyed you by criticizing your drinking?’
G=‘Have you ever felt bad or Guilty about your drinking?’
E=‘Have you ever had a drink as an Eye-opener first thing in the morning to steady your nerves or help get rid of a hangover?’
‘Yes’ to two or more indicates probable chronic alcohol abuse or dependence
Paddington alcohol test
An effective and quick alternative in the time-pressured setting of an ED is the Paddington alcohol test (PAT), which includes ‘routine’ focused selective screening combined with education, audit and feedback [32]. PAT has reduced screening time to 1 minute, simply quantifying the amount of alcohol consumed, how often and whether in the opinion of the patient the reason for ED attendance is due to alcohol.
Opportunistic screening and brief intervention
Brief intervention usually consisting of counselling lasting 10–15 minutes and a pamphlet on safe levels of regular alcohol consumption reduce the frequency of dangerous drinking by 30% and recurrent ED attendances by as much as 50%, after ED-initiated PAT screening and trained alcohol health worker follow up [33].
Focused PAT screening of high-risk patients (Table 21.4.3) followed by brief advice and referral for trained alcohol health worker brief intervention appear the most time- and cost- effective methods of reducing alcohol-related harm and ED attendances [34]. Brief advice consists of informing the patient during the ED ‘teachable moment’ that they have a drinking problem [35]. This advice increases compliance to attend brief intervention later by 20%. Using PAT to screen all ED attendances as opposed to only those presentations considered at ‘high risk’ may increase the incidental pick-up of at-risk drinkers but may also decrease the enthusiasm of ED staff to provide screening because of the time required and the many negative screens [36]. Although it has been demonstrated that ED doctors and nurses with empathy and volition can be trained to provide ED-based brief intervention on the spot, the long-term benefit of this type of brief intervention is uncertain.
Table 21.4.3
The top 10 ED presenting conditions associated with alcohol use [33]
|
Falls |
Unwell |
|
Collapse |
Non-specific gastrointestinal problems |
|
Head injury |
Psychiatric-behavioural |
|
Assault |
Cardiac |
|
Accident |
Repeat attender |
To be used with the Paddington alcohol test (PAT).
Crawford MJ, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet 2004;364:1334–9 with permission.
Pharmacotherapy for alcohol use disorder
Acamprosate
Acamprosate acts on GABA receptors in the CNS to reduce the craving for alcohol after detoxification. It is safe and well tolerated, suitable for use in treatment of alcohol-use disorder aimed at maintaining abstinence. The usual dose is 666 mg (two 333 mg tablets) orally three times daily. Mild gastrointestinal side effects may occur and therapeutic levels take 5–7 days to become established.
Naltrexone
Naltrexone is a partial opioid agonist that is useful in reducing the effects of endogenous opioids. It has had success in opioid addiction treatment, as well as in alcohol-use disorder. The usual dose is 50 mg orally daily.
These agents may be used safely in combination, although this has not been shown to have superior effect. Pharmacotherapy produces better results when used in combination with cognitive behavioural therapy and motivational sessions.
Likely developments over the next 5–10 years
ED-initiated screening and intervention for alcohol-use disorder are likely to become more widespread in EDs in coming years.
ED-initiated case management of the chronic recurrent alcohol-affected ED attender (‘inebriate programmes’) is also likely to gain favour.
Novel pharmacological agents may appear to assist treatment of alcohol intoxication, withdrawal and hangover.
Controversies
The true prevalence and incidence of alcoholic ketoacidosis is uncertain.
Use of high-dose parenteral thiamine to prevent Wernicke’s encephalopathy is somewhat controversial.
There is a question about who to target for brief intervention by emergency clinicians; high-risk attendances or unselected patients.
References
1. Australia: the healthiest country by 2020. Technical Report No 3: Preventing alcohol-related harm in Australia: a window of opportunity (including addendum for October 2008 to June 2009). Australian Government Preventative Taskforce.<http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/09C94C0F1B9799F5CA2574DD0081E770/$File/alcohol-jul09.pdf>; 2009 [Accessed Apr. 2013].
2. National Health and Medical Research Council Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Published February 2009.<http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf>[Accessed Apr. 2013].
3. Chikritzhs T, Pascal R, Gray D, et al. Trends in alcohol-attributable deaths among indigenous Australians, 1998–2004. National Alcohol Indicators, Bulletin 11 Perth: National Drug Research Institute; 2007.
4. Reynaud M, Schwan R, Loiseaux-Meunier MN, et al. Patients admitted to emergency services for drunkenness: moderate alcohol users or harmful drinkers? Am J Psychiatr. 2001;158:96–99.
5. Brokaw J, Olson L, Fullerton L, et al. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med. 1998;16:141–144.
6. Hulse GK, Robertson SI, Tait RJ. Adolescent emergency department presentations with alcohol or other drug related problems in Perth, Western Australia. Addiction. 2001;96:1059–1067.
7. Thom B, Herring R, Judd A. Identifying alcohol-related harm in young drinkers: the role of accident and emergency departments. Alcohol. 1999;34:910–915.
8. Roche AM, Watt K, Mclure R. Injury and alcohol: a hospital emergency department study. Drug Alcohol Rev. 2001;20:155–166.
9. Rosenstock S, Jorgensen T, Bonnevie O. Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish adults. Gut. 2003;52:186–193.
10. Pinto HC, Abrantes A, Esteves AV. Long-term prognosis of patients with cirrhosis of the liver and upper gastrointestinal bleeding. Am J Gastroenterol. 1989;84:1239–1243.
11. Kortas DY, Haas LS, Simpson WG, et al. Mallory-Weiss tear: predisposing factors and predictors of a complicated course. Am J Gastroenterol. 2001;96:2863–2865.
12. National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for the Use of Blood Components. Module 1 – Critical Bleeding/Massive Transfusion (released 31 March 2011)<http://www.nba.gov.au/guidelines/module1/cbmt.pdf>[Accessed Apr. 2013].
13. Lau JY, Leung WK, Wu JC, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. New England J Med. 2007;356:1631–1640.
14. Ioannou GN, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database of Syst Rev. 2003; Issue 1.
15. Roberts: Clinical procedures in emergency medicine, 5th edn. Chapter 41: Balloon tamponade of gastroesophageal varices: 754–759.
16. Gramenzi A, Caputo F, Biselli M, et al. Review article: alcoholic liver disease – pathophysiological aspects and risk factors. Aliment Pharmacol Ther. 2006;24:1151–1161.
17. Suokas J, Lonnqvist J. Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms. Acta Psychiatr Scand. 1995;91:36–40.
18. Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addiction. 1989;84:1353–1357.
19. Williams D, Lewis J, McBride A. A comparison of rating scales for the alcohol withdrawal syndrome. Alcohol Alcoholism. 2001;36:104–108.
20. Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence based guidelines. J Am Med Assoc. 1997;278:144–151.
21. Palmstierna T. Model for predicting alcohol withdrawal delirium. Psychiatr Serv. 2001;52:820–823.
22. Galvin R, Brathen G, Ivashynka, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol. 2010;17:1408–1418.
23. Sechi GP, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6:442–455.
24. McGuire LC, Cruickshank AM, Munro PT. Alcoholic ketoacidosis. Emerg Med J. 2006;23:417–420.
25. MacDonald L, Kruse JA, Levy DB. Lactic acidosis and acute ethanol intoxication. Am J Emerg Med. 1994;12:32–35.
26. Constant J. The alcoholic cardiomyopathies – genuine and pseudo. Cardiology. 1999;48:91–92.
27. Shpilenya LS, Muzychenko AP, Gasbarrini G. Metadoxine in acute alcohol intoxication: a double-blind, randomized, placebo-controlled study. Alcohol Clin Exp Res. 2002;26:340–346.
28. Weise JG, Shiplak MG, Browner WS. The hangover. Ann Intern Med. 2000;132:897–902.
29. Pittler MH, Verster JC, Ernst E. Interventions for preventing or treating alcohol hangover: systematic review of randomised controlled trials. Br Med J. 2005;331:1515–1518.
30. Phillips GA, Brophy DS, Chenhall AJ, et al. The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department. Med J Aust. 2006;184:602–606.
31. Greane J. Serial inebriate programmes: what to do about homeless alcoholics in the emergency department. Ann Emerg Med. 2007;49:701–703.
32. Nilssen O, Ries RK, Rivara FP. The CAGE questionnaire and the Short Michigan Alcohol Screening Test in trauma patients: comparison of their correlations with biological alcohol markers. J Trauma. 1994;36:784–788.
33. Crawford MJ, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 2004;364:1334–1339.
34. Touquet R, Brown A. Alcohol misuse: positive response Alcohol health work for every acute hospital saves money and reduces repeat attendances. Emerg Med Australas. 2006;18:103–107.
35. Williams S, Brown A, Patton R, et al. The half-life of the ‘teachable moment’ for alcohol misusing patients in the emergency department. Drug Alcohol Depend. 2005;77:205–208.
36. Weiland TJ, Dent AW, Phillips GA, et al. Emergency clinician-delivered screening and intervention for high-risk alcohol use: a qualitative analysis. Emerg Med Australas. 2008;20:121–128.
21.5 The challenging patient
Sandra L Neate and Georgina A Phillips
Essentials
1 Many patients characterized as ‘challenging’ share common characteristics, including complex and chronic medical disease, mental illness, marginalization, poverty, high levels of drug and alcohol use and lack of social supports, safety and security.
2 An understanding of the issues that contribute to the challenging nature of some patients may assist the practitioner in developing a management approach characterized by sound knowledge, clear and achievable goals and compassion.
3 Management strategies may help to alleviate the dissatisfaction and frustration frequently experienced by the clinician.
4 Allied health and psychiatric services in the emergency department facilitate multidisciplinary and holistic care for the patient with complex needs.
5 Safety and security for all patients and staff must be assured.
Introduction
The emergency department (ED) may be the only easily accessible healthcare for patients with multiple and challenging needs. For those impaired due to chronic illness, drugs and alcohol, mental illness or social circumstances, the ED is an environment where services are available 24 hours a day or during crisis. The challenges posed by complex patients are compounded by system factors, such as decreased after hours’ services, ED overcrowding and access block. Some patients require urgent management for reasons other than medical issues, for example, a behaviourally disturbed patient who causes disruption and threatens violence within the ED, a VIP who may distract the attention of staff or someone who poses a security risk. The management of a complex patient in a difficult environment represents a common challenge for emergency physicians. All emergency staff may find dealing with challenging patients tiring and frustrating and experience feelings of dissatisfaction. Several types of patients are described and discussed, with the aim of understanding the circumstances that contribute to these presentations and assisting the practitioner to develop an approach to management.
The homeless patient
Essentials
1 Multidisciplinary management of the homeless person is required.
2 Discharge planning is difficult and short-stay admission is frequently required.
Definition and epidemiology
Definitions of homelessness vary. A homeless person is often considered to be someone living on the streets without shelter. A broader definition includes any person without a conventional home who lacks most of the economic and social supports that a home normally affords. These persons are often cut off from the support of relatives and friends, have few independent resources and often no immediate means and, in some cases, little prospect of self-support.
The most widely accepted definition in Australia, and the one used by government and other specialist agencies to gather data, describes three kinds of homelessness:
Primary homelessness, such as sleeping rough or living in an improvised dwelling.
Secondary homelessness including staying with friends or relatives and with no other usual address, people in specialist homelessness services.
Tertiary homelessness including people living in boarding houses or caravan parks with no secure lease and no private facilities, both short and long term [1].
Concepts of homelessness vary with culture. People from Aboriginal and Torres Straight Islander cultures may experience homelessness when separated from their spiritual home despite adequate shelter and, conversely, may feel a spiritual connection to the land on which they live independent of the presence of shelter. Three broad categories of indigenous homelessness are identified in Australia: those living in public places, those at risk of losing their house and those who are spiritually homeless [2].
Estimates of prevalence of homelessness are difficult due to variations in definition and methodologies of identification. Every night in Australia, around 105 000 people are homeless [3]. More than 160 000 Australians experience homelessness each year, one-third of them children, while resources allocated in response to homelessness are grossly inadequate. Homelessness is more prevalent in women and is closely related to the experience of domestic violence and inequity in general. Homelessness among children, families and older people is increasing. The Australian indigenous population comprises 2–3% of the Australian population but accounts for 18% of those accessing homeless services primarily as a result of domestic and family violence, overcrowded dwellings and evictions [4]. Ex-prisoners, war veterans, the mentally and physically ill, people leaving healthcare facilities and protective services, youths and people in rural communities experience increased incidence of homelessness.
Clinical features
Homeless patients presenting to the ED exhibit high rates of complex physical and mental illness and substance dependence. Due to poverty and social isolation, access to healthcare is impeded with a subsequent cycle of deterioration in health. Lack of housing stability, social supports and points of reference within the local community lead to a high rate of utilization and re-presentation to the ED despite the development of outreach programmes or case management strategies [5]. Homeless patients may present to the ED up to 10 times more frequently than the rest of the population [6].
Re-presentation rates within 28 days of discharge are high and may account for up to 48% of all re-presentation episodes and 23% of all patients who re-present to the ED [6]. Certain features, such as sociodemographics (age<65 years, receiving government pension), service utilization history (case management and discharge at own risk) and clinical features (primary psychiatric presentation, complex medical history and high numbers of prescribed medications), are highly predictive of re-presentation [6,7]. Presentations by homeless people are often of low acuity. Triage categories are non-urgent in up to 91% of attendances [6].
Presentations with infectious diseases (e.g. TB and HIV), penetrating trauma, depression, schizophrenia and ethanol and drug abuse are common. Deliberate self-harm presentations are more frequent and are followed by a higher rate of re-presentation with recurrent self-harm and approximately double the rate of death from successful completion of suicide than in the domiciled population [8]. Homeless patients presenting with deliberate self-harm are more likely to be a recent victim or perpetrator of violence or have a criminal record or a personality disorder, thus highlighting the complex links between these variables.
Management
The management of the homeless patient requires a multidisciplinary approach and an understanding of the social and financial constraints the patient faces. Allied health services may be able to provide background information or links to established community services, assist with discharge planning or assist with emergency accommodation or other social services. Discharge planning may be especially difficult and short-stay admission for management of simple conditions normally treatable at home or admission to low acuity facilities may assist with improvements in health and other social parameters. A compassionate approach to the homeless patient, where patients were assigned a volunteer who offered food and conversation, was found to decrease significantly rates of re-presentation, dispelling the myth that increasing patient satisfaction encourages homeless patients to re-attend [9].
The prisoner
Essentials
1 The prison population is disadvantaged and vulnerable.
2 Prisoners’ health needs differ from the general public.
3 Presentations are often injury related and are generally of high acuity.
4 Security events are uncommon.
Definition and epidemiology
In all states and territories except Queensland, prisoners are defined as persons greater than 18 years remanded or sentenced to adult custody (age 17 in Queensland) [10]. The patient brought to the ED by police from the community under arrest differs from the patient who is residing in prison. Both types of patients may pose security issues, but their health needs and demographics differ.
The prisoner poses several challenges when seen in the ED (Table 21.5.1).
Table 21.5.1
Challenges involving the prisoner in the ED
|
Security issues |
Patient care issues |
|
Perceived threat to safety of staff and other patients |
Clinical management of complex illness |
|
Potential for violent incidents |
Medical, psychiatric and addiction co-morbidities |
|
Presence of non-hospital security staff |
Maintenance of confidentiality |
|
Weapons in the ED |
Discharge planning |
The prison population in general, has low educational achievements, poor records of employment, high reliance on social welfare, poor nutrition and more complex physical and mental health needs when compared with the general population and, from a health perspective, represents a cohort of patients distinct from the wider community [11].
Prisoners have a high rate of pre-existing mental and physical illness, substance use and dependence and high rates of hospitalization. Twenty-five per cent of prisoners report having been hospitalized in the preceding year [11]. Prisoners have a high rate of risk-taking behaviours that increase the risk of poor health, such as tattooing and heavy alcohol and substance use, and display behaviours with addictive or compulsive orientations and low impulse control. These factors contribute to the illnesses experienced, modes of presentation and the responses to health staff and treatments offered.
Clinical features
The mean age of prisoners presenting to the ED is approximately 30 years, however, as with the general community, the prison population is ageing rapidly [12]. Presentations are most commonly injury related, with approximately one-third self-inflicted injury, one-third accidental and one-third as a result of assault or unclear mechanisms. Prisoner injuries seen in the ED are overall more severe when compared with those in the general male population, with a higher frequency of fractures, blunt head injuries, greater rates of hospital admission and death [13].
Mental health issues are common among prisoners and incarceration is more common in those with mental illness. Risk factors for incarceration for those with mental illness include prior incarcerations, substance-related diagnoses, homelessness, schizophrenia, bipolar or other psychotic disorder diagnoses and male gender [14]. Risk of suicide is high among prisoners with factors specifically related to incarceration, such as isolation, punitive sanctions, severely restricted living conditions and acquisition of new charges or imposition of an unexpected sentence, elevating risks substantially [15].
Substance withdrawal is implicated in approximately 9% of presentations and 6% of admissions [16]. Due to the increased risk of overdose following periods of abstinence, recently released inmates who use opiates are at particularly high risk of overdose and overdose deaths are eight times more likely in the 2 weeks following release than in a comparable non-incarcerated group of men [17].
Prisoners have a high rate of admission to hospital (range 36–49%), which may be due to higher acuity of illness, with approximately 80% of prisoners triaged as category 3 or above, and the practical and logistical difficulties in managing unwell people in custody. Prisoners have a decreased length of stay in the ED compared with the non-prisoner population [16].
Violence and security issues
Episodes of violence are uncommon. The rate of security incidents may be lower than for the non-prisoner population [16]. Perceived threat and the accompanying stress caused to staff are yet to be quantified.
The presence of weapons provides the potential for serious injury to the patient if escape is attempted or to staff if the patient removes a weapon from security staff. Fatalities have been documented [16].
Management
The urgency with which a prisoner is assessed depends on a combination of medical issues and security considerations; prioritization, in order to expedite managment and decrease length of stay in the ED, is reasonable.
Prisoners may perceive the ED as a threatening, embarrassing environment that lacks privacy, where they can be seen by members of the public to be under guard and restrained. Most express feelings of distress when removed from their familiar environment. Prisoners are unable to have the normal reassurance and support of family while in hospital. The presence of guards during medical assessment raises confidentiality concerns for the patient. These concerns need to be weighed against security issues. Guidance from custodial staff as to whether it is safe for them leave the cubicle or remove restraints may be helpful. If the clinician feels insecure, custodial staff should remain within the room. The history obtained in the presence of guards may be inaccurate. Patients may be fearful of disclosing the mechanism of injuries due to fears of reprisal or prison guards in attendance overhearing the circumstances of injury.
In many Australian states, psychiatric services are not resourced or mandated to care for prisoners and mental health acts do not cover those incarcerated under separate forensic laws. This may render the ED care of the mentally unwell prisoner even more difficult, as psychiatric illness may be undiagnosed or undertreated and access to normal mental health clinicians to aid in assessment and treatment may not be available.
Opportunities for follow up of medical conditions are limited. There may be little possibility for observation of the person’s condition upon return to detention. Outpatient follow up is time and resource intensive and logistically difficult for the prison staff. There is therefore often a need for more extensive investigation while in the ED. A low threshold for ruling out potential illnesses and for admission to hospital is generally required.
If the patient is returning to prison, clear written discharge instructions should be formally communicated and discharge medication with dispensing instructions provided. Liaison with the prison nurse or forensic medical officer should establish whether their facilities and staffing can provide the expected management.
The behaviourally disturbed and violent patient
Essentials
1 Complex co-morbidities of organic illness, psychosocial issues and substance misuse can manifest as acute behavioural disturbance.
2 Understanding legal and ethical considerations can inform rapid decisions and humane treatment in behavioural emergencies.
3 A safe environment and team approach can maximize containment of disturbed and violent behaviour, while respecting the privacy and dignity of patients.
4 A strategic approach to understanding and managing violence in the ED may minimize the harmful effects of violence to staff, patients and carers.
Aetiology and epidemiology
A behavioural emergency can be defined as an unarmed threat by a patient or others characterized by agitation, aggression, violence and irrational or altered behaviour. Violent and unarmed threats involving patients in the ED have been described with an incidence of between 0.3% [18] and 2% [19]. Accurate information on the incidence and subsequent management of acute behavioural disturbance is limited by the lack of clarity around what constitutes a behavioural emergency and significant differences in treatment response both within and between EDs. Heavy recreational drug use and alcohol binge drinking in the community have contributed to the public perception that behavioural disturbance requiring urgent medical care has increased. It has also been argued that psychiatric deinstitutionalization and limited community supports have led to an influx of unstable, mentally ill patients to the ED.
Approximately half of the patients presenting with acute behavioural disturbance have an acute flare of a primary mental illness, while 40–50% are intoxicated with drugs or alcohol [18]. A smaller number have an organic illness, including dementia, manifesting as a behavioural emergency [20]. A combination of psychiatric illness and substance intoxication commonly occurs. Most patients are male (approximately 65%) and under the age of 40 [18,21], and around 20% are brought to the ED in police custody [18,22]. The majority of unarmed threats occur in the late afternoon, evening and overnight, with a weekly peak on a Saturday[18]. Between 58 and 80% of these require some form of chemical or physical restraint as part of management [18,19,21].
Prevention
There are no validated tools or clinically useful predictive factors for violence and acute behavioural disturbance in the ED; however, experienced clinicians are able to recognize environmental and individual factors that can lead to unstable and dangerous behaviour. Crowded, noisy and brightly lit departments are the antithesis of the calm and stable surrounds that promote controlled behaviour and de-escalate aggression. Fear, confusion and inadequate communication can trigger anger and aggressive behaviour in both patients and carers, while long waiting times and negative waiting room environmental factors have been suggested as contributors to violence in the ED.
In order to prevent anger or illness from escalating to a behavioural emergency, recognition of verbal and non-verbal cues is required, as well as an ability to utilize environmental and clinical resources to ensure a calm, controlled situation. EDs are now incorporating separate rooms or areas that are quiet, private and secure, as sites for the assessment and containment of behavioural disturbance. This model has become the recommended standard in Australia for assessing and containing aggressive and agitated patients both at a national [23] and state level [24]. Physical separation from the main ED and removal of stimulation may be enough to reverse the trend to increased aggression. Respectful and clear communication with lowered voice level, eye contact and non-threatening body language may establish a rapport that enhances a therapeutic bond between clinician and patient. Explanation of treatment decisions and the reasons for them may alleviate confusion, while bargaining and rewarding compliance can diffuse tension. Allowing a semblance of autonomy and control to the patient, while setting clear behavioural limits, is recommended.
A ‘security response’ is utilized in the ED to contain behaviour when disturbance and aggression can be anticipated [25]. This is aided by prior police and ambulance notification of the imminent arrival of a patient with a behavioural emergency. A team comprising hospital security service, nursing and medical staff can in itself be a disincentive for increased aggression, when confronting an aroused patient. In the event of violence, the team response carried out in a separate area of the ED can quickly control behaviour safely and thus prevent further episodes or prolongation of aggression.
Clinical features
Clinical assessment comprises three components: diagnostic, evaluation of risk and assessment of arousal (Table 21.5.2).
Table 21.5.2
Aims of clinical assessment in acute behavioural assessment
|
Diagnosis |
What is the aetiology of the behaviour: psychiatric, substance related, organic, personality? |
|
Risk assessment |
Can the patient’s autonomy be over-ridden? Can I keep them in the ED against their will? |
|
Arousal assessment |
Does the patient require containment or sedation and how rapidly? |
Signs of acute intoxication or withdrawal may follow recognized patterns or drug toxidromes, while psychiatric instability may manifest with features of psychosis. Differentiating between organic illness, delirium and substance intoxication or psychosis can be extremely difficult in the initial assessment and may only be clarified after immediate management and behaviour containment. A breath alcohol determination is useful and intravenous puncture sites may suggest substance misuse. In an agitated and aroused patient, the act of taking a blood pressure or putting a stethoscope on the chest may be recognized as a familiar and non-threatening action and thus be better tolerated than attempting to get a detailed history or expecting a rational response to verbal requests.
The role of investigations in the behaviourally disturbed patient is controversial. Routine laboratory blood testing is of low yield and diagnostic evaluation should be directed by history and examination. Urine drug screens have no role in the acute assessment or management. Cognitive abilities should guide the readiness for psychiatric assessment, rather than the suspected presence of drugs or alcohol. A positive breath alcohol should not preclude mental health assessment in the patient who is alert and orientated [26].
Risk assessments are often made rapidly and intuitively in the highly agitated and aggressive patient. The decision to contain and restrain an aroused patient with extreme behaviour is primarily based around the perceived threat of harm to self or others. If patient competence cannot be assessed, then the assumption of risk of harm and the doctor’s duty of care override patient autonomy. Clinical features that are suggestive of high risk include threats or actual self-harm, suicidal behaviour or ideation, threats or actual violence to others, altered conscious state due to illness, injury or substance intoxication and incompetence. Risk assessments and restraint can only be made within an acute framework (i.e. pertaining to hours rather than weeks or months), as this is the length of time a person can humanely be contained within an ED setting. Patients with longer-term high-risk behaviours are not suitable for physical or chemical restraint in the ED and may be managed more appropriately in a mental health or forensic setting.
Assessment of arousal requires utilization of collaborative and clinical tools and informs decisions about urgency and methods of restraint. Information about behaviour immediately prior to ED presentation can be gathered from police and ambulance officers. Physical struggle and violence requiring restraint during transport to the ED is an indication of the need for ongoing restraint. Physical intimidation, threats or acts of violence to self, people or property, attempts to escape, uncontrollable verbal abuse and aggressive acts, such as spitting, all indicate extreme arousal and the need for immediate containment and restraint. Signs that a patient is increasingly aroused and that violence may be imminent, include physical agitation and restlessness, pacing, sweating, loss of rational thinking, increased voice tone, swearing or foul language, eye widening and pupil dilation. Early recognition of these prodromal features may prevent the escalation of aggression and ensure the safety of both staff and patient.
Legal and ethical considerations
Sedation and restraint for behaviour containment represent significant deprivations of personal liberty. Australasian law strongly upholds the fundamental principle of individual autonomy and mental health legislation mandates a ‘least restrictive’ approach to involuntary care. Emergency physicians must also respect patient autonomy and be mindful of employing the least restrictive practices when making decisions to restrain aroused and aggressive patients (see Chapter 25.1).
The ability to detain and treat people without their consent is lawfully recognized in emergency situations, committal under legislation (e.g. mental health acts), suicide prevention, to protect others from harm, self-defence, ‘necessity’ or ‘in best interests’ and for incompetent patients [27]. Thus, ED staff are comprehensively protected under the law if they act in good faith and with integrity when managing acute behavioural disturbance. Doctors are also legally required to maintain confidentiality, to take reasonable care, not to take advantage of a patient and to meet professional standards. Containment and restraint often take place in highly visible sites within the ED, where the patient is exposed to the scrutiny of other staff, patients and visitors, which can undermine personal privacy and confidentiality. Similarly, abusive and aggressive patients may provoke anger and frustration in ED staff. Competent patients are responsible for their actions and are expected to behave within a reasonable and legal framework. Damage to property and assault to person are crimes which are subject to prosecution if they occur in an ED and towards ED staff. There are occupational health and safety requirements that mandate a safe working environment and can inform structural changes and clinical practices in the management of violence in the ED.
Medical ethics and the law complement each other when recognizing personal autonomy and human rights. A compassionate approach that respects the human dignity of all patients and recognizes the medical duty to provide care is likely to result in both a lawful and an ethical framework for managing patients with behavioural emergencies.
Management
Once the decision to contain and restrain a patient with behavioural disturbance has been made and preventative, de-escalation measures have been unsuccessful, it is worth determining the desired endpoint of management. Containment methods differ significantly according to the desired outcome, which may range from a calmed, awake patient through to one who is fully tranquillized and physically restrained. In an ED setting, containing and restraining a patient is not therapeutic and should be viewed as a transient departure from the normal physician–patient collaboration.
Containing a highly aroused and aggressive patient requires a team of trained staff: a minimum of six people comprising hospital security staff and orderlies, with medical and nursing staff to assist with team leadership, documentation, drug administration and subsequent monitoring [28]. Smaller hospitals may need to utilize police in their initial team response, but this is not recommended, given the differing training and aims of hospital- and police-based restraint practices. Police should be involved when a weapon is present or the violent person is not a patient receiving treatment. The importance of prior planning, regular aggression management training and good communication cannot be overemphasized.
Chemical restraint
The pharmacological management of the acutely aroused patient is discussed in detail elsewhere (see Chapter 20.6), but the principles should be emphasized. The least traumatic measures are advocated, depending on the desired endpoint of chemical restraint and the risks to staff and patient in administration.
Oral benzodiazepines are preferred where possible and may allow patients a small sense of control if they are able to choose this option ahead of parenteral sedation. Choice between intramuscular or intravenous administration of sedation depends on perceived risks to staff, ease of obtaining intravenous access, need for blood tests or other intravenous therapy and desired rapidity of sedative effect. Where rapid tranquillization is desired, the intravenous route of administration is required, as the onset of action is within the first 5 minutes rather than the approximate 15–20 minutes of intramuscular drugs [29,30]. Commonly used drugs for rapid tranquillization include benzodiazepines (diazepam and midazolam), neuroleptics (droperidol and haloperidol) and newer antipsychotics (olanzapine). A combination of intravenous midazolam with droperidol or olanzapine has been shown to be more effective than midazolam alone with respect to time to adequate sedation and need for re-sedation [31]. Intravenous midazolam alone may cause more adverse events relating to airway obstruction and oversedation and is more likely to require re-sedation within an hour. High dose parenteral midazolam is not supported due to concerns about effect and safety [32].
Other drugs used for less urgent or longer-term sedation include benzodiazepines administered intramuscularly or orally, intramuscular neuroleptics and other antipsychotics, including olanzapine. Combinations of these drugs are often used, although unpredictable intramuscular absorption and an additive sedative effect can result in oversedation. Careful monitoring in a high acuity area of the ED is required when parenteral chemical restraint is used.
Physical restraint
Physical restraint can initially proceed on the floor and move to a trolley as soon as practical. A five-point hold is recommended, involving securing the head, upper and lower limbs in firm grasps. Personal protective gear of gown, safety goggles and gloves should be worn by all involved and an oxygen mask or loosely applied towel over the face can be used if the patient is spitting. While it is paramount not to inflict harm on the patient, the safety of staff is also a priority and may justify the use of moderate physical force. Using staff physically to restrain a patient is a temporary measure only and should be followed by more definitive restraint in the form of sedating drugs, physical shackles or both.
Physical restraint with shackles provokes emotional distaste in many clinicians, but it can be used safely and humanely in an ED setting. There have been reported deaths in restrained, agitated patients, described largely in the USA where ‘hobble’ restraints including prone positioning with hands and feet secured together behind the back are used [33]. Where supine positioning is used, physical shackles have been shown to be safe [34], although caution should be employed with restraints around the upper chest and neck area. Soft-edged, strong, fabric shackles securing the wrists and ankles of a supine patient to the trolley are recommended. Concomitant chemical sedation is advised with appropriate monitoring. Prolonged shackling is inhumane and carries risks of musculoskeletal injury, respiratory compromise and psychological trauma. All Australian states have laws that mandate careful and close observation of physically restrained patients, as well as regular review of the need for such ongoing, extreme restraint.
While few EDs have appropriate resources, it may be possible to contain patients with behavioural disturbance in a less restrictive manner by using seclusion rooms. Such areas must be visible to ED staff, be easily accessible to a security response team and have no dangerous furniture or fittings with which patients could potentially harm themselves or others.
Patient perspective
Emergency clinicians rarely consider patient preferences when faced with the need urgently to control aggressive or threatening behaviour and there is limited evidence to inform this issue. The majority of patients prefer chemical restraint rather than physical for interventions and seclusion is preferred over physical shackles. Benzodiazepines are the preferred drug for chemical sedation rather than neuroleptics [35].
Disposition
Behaviourally disturbed patients commonly spend many hours in the ED, both for accurate assessment and for diagnostic purposes. Increasingly, the lack of access to general medical, psychiatric and detoxification inpatient beds means that timely transfer for definitive care is delayed. The result is prolonged, inhumane containment of behaviourally disturbed patients, which is likely to lead to worse therapeutic outcomes. For this reason, ED doctors must be strong advocates on behalf of their patients, as well as maintaining vigilant clinical review of physical and mental state and the need for ongoing restraint. Patients who are transferred to inpatient wards for ongoing care must be alert, have stable vital signs, not require further monitoring and be declared safe for transfer by the most senior available ED clinician. Respiratory depression and death have occurred in patients transferred to psychiatric wards after receiving chemical sedation from the ED; therefore, the time, nature and route of drug administration must be taken into account when considering safety for transfer.
The decision to admit a patient depends on the result of clinical and investigative findings, ongoing mental health and risk assessment and the progress of the patient over time. It is appropriate to keep behaviourally disturbed patients under ED observation for up to 24 hours in order to clarify the aetiology of the altered behaviour and determine a safe disposition. Patients with aggression and arousal due to substance intoxication often wake up several hours later with normal behaviour and no recollection of their earlier violent behaviour. This presents a preventative health opportunity to counsel, educate and refer the patient for ongoing drug and alcohol review. Patients should be informed that their substance misuse resulted in dangerous behaviour both for themselves and others, but many will already be socially marginalized and vulnerable as a result of homelessness, substance addiction and psychosocial stressors. A multidisciplinary care-coordination approach optimizes a safe discharge for these patients.
Normal clinical and investigative findings, the absence of substance intoxication and exclusion of acute mental illness mean that the patients do not require further ED care. Such patients may still present a behavioural challenge and, if ongoing risk to self or others exists, then they should be discharged to the care of the police. Collaborative decision making with mental health clinicians is often required in such situations, as these patients often suffer antisocial or other personality disorders that are difficult to manage in both forensic and health settings. For those discharged to the community, mental health and social work follow up is recommended.
At all stages in the assessment, containment, restraint and disposition of patients with acute behavioural disturbance, clear documentation is mandatory. The importance of recording management events and the reasons behind containment or discharge decisions protects staff from clinical and legal criticism, as well as aiding care in potential future ED presentations.
Violence
The impact of violence is under-recognized in Australasian EDs, although it has been increasingly documented [36]. Aggression and violence most often stem from acutely disturbed patients, although violence in the ED can also come from visitors and carers, as well as hospital staff. Internationally recognized as a growing problem, ED violence is also generally poorly documented and under-reported, with limited formal hospital support for those exposed and rare conviction for the perpetrators [37,38]. While conventional definitions of violence centre around the act of intent to cause physical or psychological harm, in an ED setting, aggression and violence are commonly a manifestation of underlying illness or substance intoxication. The absence of a malicious intent to cause harm may be a reason why violence has been under-recognized in the hospital environment and has led to an alternative workplace definition: any episode in which staff experience either implicit or explicit challenges to their personal safety, health or sense of well-being [39].
Other reasons for under-reporting of ED violence stem from hospital systems which act as barriers by burdening staff with excessive and time-consuming paperwork, confusing policies, inadequate confidentiality and lack of peer support. While most episodes of violence in the ED do not result in serious physical injury, staff who experience violence may be traumatized, which can lead to feelings of stress and anger. The cumulative effect of violence may result in clinician ‘burnout’ and staff attrition.
Three core components comprise a strategic approach to managing violence in the ED: environment (appropriateness, safety); staff (education, training, teamwork); and systems (reporting, follow up, peer support). Prevention and early intervention within a safety and patient-care framework is emphasized.
Generally, a comfortable environment with clear visibility that facilitates good communication will have a greater effect on behaviour modification than increasing fortification of waiting rooms, triage and clinical areas in the ED. Violence minimization is assisted by security cameras and televisions at triage so potential aggressors can see that they are being monitored, the visible proximity of security staff, high visibility within the clinical workspace, restricted access areas, minimizing access to potential weapons, widely dispersed and simple-to-use duress alarm devices. Weapon searches and metal detectors are rarely used in Australasian EDs and the introduction of such measures may compromise the welcoming and therapeutic atmosphere that should characterize an ED. Introducing armed security personnel into EDs increases risk to staff and patients and is not recommended [24]. Staff training and support is paramount in managing ED violence. Interdisciplinary programmes that involve role-play and real scenario discussions can enhance cooperation between all ED staff, while clarifying roles and responsibilities during actual security responses. Peer education sessions can serve to change culture towards a preventative and proactive approach, based on good communication skills and sound knowledge about behavioural emergencies. Hospital security staff are experts in the containment of aggressive and violent patients within a healthcare framework and can lead team-based prevention and safety training for ED staff.
In general, ED doctors are required to take a leadership role when managing a violent episode, although collaboration with experienced nursing colleagues improves care. Awareness of personal factors that may affect the escalation of violence and the subsequent outcomes is therefore essential. Anger, fear and personal insult can lead to interactions with aroused patients that may escalate aggression rather than diffuse tension. The role of peer support and follow up in such situations is vital. Similarly, issues of gender, language and culture are often under-recognized as factors influencing the escalation and management of a behavioural emergency. Male staff may experience higher levels of physical violence than women. Self-awareness and consideration of these issues can optimize management of the violent episode, as well as minimize the potential negative outcomes for staff and others.
The final component of the structured approach to ED violence management is ensuring adequate documentation and follow-up systems, which include debriefing and support. Reporting should be incorporated into the standard documentation of any security incident within the ED, rather than the onus of staff who have been victims of violence. As the issue of workplace violence is one of occupational health and safety, follow up of violent incidents should fall within this framework, thus depersonalizing the impact of aggression and owning violence as an organizational responsibility rather than one belonging to the individual.
The frequent attender
Essentials
1 Frequent attenders to the ED have increased morbidity and mortality.
2 Assumptions about inappropriate use of the ED have been shown to be false.
3 ED-based multidisciplinary care coordination can lead to improved psychosocial status for frequent attenders.
Definition and epidemiology
Patients who present to hospital EDs more than three times a year can be defined as ‘frequent attenders’ [40] and represent a particularly vulnerable population [41]. Both internationally and within Australasia, the frequent attender population has consistent characteristics that include poverty, homelessness, chronic and complex medical illness, psychiatric illness and drug and alcohol abuse [42–44]. Frequent attenders also suffer a high mortality, with an increased risk of death from violent causes, such as suicide and substance misuse [45]. They are known to use health services in a frequent, chaotic and episodic way, often attend multiple EDs and are difficult to engage in any long-term care. Importantly, availability and engagement with primary healthcare providers does not alter ED use by frequent attenders [46].
While representing a small number of people, frequent attenders can be responsible for up to 8% or more of annual ED attendances [47]. Demographic details vary according to how the frequent attender population is defined and analysed in the literature, although they are consistently more likely to be male, older and socially isolated [5,41]. A range of 27–55% have chronic and complex medical illness as the key reason underlying their frequent ED use, while the remainder suffer primarily psychiatric, social or drug- and alcohol-related illness [5,48]. Commonly, heavy ED users display a combination of all of these co-morbidities. Patterns of attendance generally fall into two categories, with those suffering primarily psychosocial illness or substance abuse sustaining consistently frequent ED use over many years, while those with primarily chronic medical illness showing peak ED attendance over 1–2 years [48]. Recent research from New Zealand demonstrates the natural attrition of frequent ED attenders over time [49]; however, the principal finding in studies around the world is the high mortality of this population.
Clinical features
There is great variability in the clinical presentation of frequent attenders. Acute exacerbations of underlying chronic medical illness are common as are traumatic injuries or injuries and illness sustained through violence or substance misuse, including acute substance intoxication. Infections in the respiratory, gastrointestinal and dermatological systems are frequent. Deterioration in mental state or self-harm and suicide attempts are also common reasons for ED attendance [47]. Compared with the whole population, frequent attenders are more likely to present out of hours [50], have more serious and urgent illness and more often require inpatient services [41]. Frequent attenders are more likely to discharge themselves from the ED prior to completing their ED care or self-discharge before assessment after the initial triage process [47].
There is a pervasive assumption that frequent attenders present to the ED excessively and unnecessarily and are therefore suitable for diversion to general practitioners. Evidence suggests that this belief is false and that the majority of patients presenting frequently for ED care do so appropriately and are unsuitable for diversion to primary-care providers [47]. Patients may be adversely affected if their symptoms are belittled and attendance classified as ‘inappropriate’ [51].
Management
Understanding the vulnerability of frequent attenders and their complex co-morbidities while adopting a humane approach is fundamental. Medical care follows standard procedures. Access to past history and information from all healthcare and community services involved in the care of the frequent attender provides an essential context enabling timely, focused and relevant care, without unnecessary duplication of services and investigations. The development and wide dissemination of individualized acute care plans can assist in streamlining assessment and management when frequent attenders re-present to the ED after hours. Utilization of ED-based multidisciplinary services for care coordination has been shown to be of benefit when caring for the frequent attender [5].
Attempts to reduce perceived unnecessary ED attendance have met with varying results. Neither education of patients nor management care plans has reduced the frequency of ED attendance. The most successful international diversion strategies have adopted multidisciplinary approaches, including social worker support [52,53]. ED-based multidisciplinary case management has been shown to increase ED utilization but also to lead to improvement in psychosocial factors, such as housing status and engagement with primary- and community-care providers [5]. ED use may need to increase for frequent attenders if psychosocial improvements are desired.
Frequent attenders are a complex, unwell and chaotic population. Diversion away from the ED has no proven patient benefit, therefore, it may be that the ED is the best site of care for such vulnerable patients and can have a role in improving overall well-being.
The patient with drug-seeking behaviour
Essentials
1 Drug addiction can be viewed as a chronic, organic disease.
2 Drug-seeking behaviour is problematic for the patient and the clinician.
3 Physicians managing these patients may experience dissatisfaction, frustration and feelings of manipulation.
Definition and aetiology
Drug abuse is defined as a maladaptive pattern of drug use indicated by continued use despite knowledge of having a social, occupational, psychological or physical problem that is caused or exacerbated by the use [54]. Addiction is defined as a primary, chronic neurobiological disease that develops as a result of genetic, psychosocial and environmental factors and manifests as use of a substance to the extent that the user is periodically or chronically intoxicated, exhibits compulsive use, has great difficulty in voluntarily ceasing or modifying substance use and exhibits determination to obtain psychoactive substances by almost any means. Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted [54]. Drug-seeking behaviour can be defined as behaviour aimed at obtaining controlled substance prescriptions for reasons of dependence, abuse or illicit use in a manner that is problematic to the prescriber [55]. Patients may have a range of underlying disorders, such as psychiatric illness, substance misuse, chronic pain and complex medical conditions, which have resulted in drug dependence and institutionalized behaviour on many levels.
The concept of addiction as a disease is useful in modifying the clinician’s approach to patients with addiction issues. The illness model has countered the widely held view of addiction as a wilful behaviour with moral implications. Likening addiction to other chronic illnesses, such as hypertension and diabetes, helps to understand the chronicity of the problem and the vulnerability to relapse. The rehabilitation of patients with substance-abuse problems has, however, been handled largely by non-physicians who work closely with their patients. The ongoing nature of the treatment and the relationship required to effect treatment makes intervention in the ED challenging.
Clinical features
Identification of the patient seeking drugs may be difficult. Features raising suspicion of drug seeking include previous suspicions of drug seeking documented in the medical record, inconsistent history or examination findings, requests for specific narcotic or other drugs of dependence, unwillingness to try simple analgesia, higher than expected analgesia requirements and demanding or aggressive behaviour. Other features that may raise suspicion include complaints of lost or stolen prescriptions or medications, letters from remote medical practices supporting the provision of medications and presentations that are possible to feign, such as migraine or ureteric calculus.
Presenting problems of those diagnosed as drug seeking include acute and chronic pain, primary psychiatric disorder or drug and alcohol dependence or specific request for medication. Patients exhibit a high rate of previous attendances with drug-seeking behaviour and, commonly, have a past history of mental illness, drug dependence and self-harm [56].
The possibility of missing organic illness is considerable in patients suspected of drug seeking, as nearly 20% require hospital admission and 17% self-discharge against medical advice. Missed, too, is the opportunity to acknowledge drug dependence and refer appropriately. Of drug-seeking patients seen in the ED, only 11% have a documented discussion around this issue in the medical record and only 23% are referred to addiction, psychiatric or chronic pain services [56].
Management
There is considerable individual variation in the management of patients who are drug seeking. Clinicians often find these interactions frustrating and unsatisfying and may feel abused or manipulated. The development of a general approach may assist (Table 21.5.3).
Table 21.5.3
General approach to the drug-seeking patient
Attempt to develop rapport with the patient
Ensure that new organic pathology does not exist
Determine that genuine pain has been adequately treated
Once the physician has some degree of certainty that problematic drug-seeking behaviour exists, set clear limits regarding medications requested
Consider the possibility of open discussion with the patient regarding the behaviour
Consider referral to appropriate services for ongoing care
Develop management protocols for particular patients if frequent attendance or threatening behaviours develop
Limit setting requires confidence, experience and familiarity with local laws that limit the prescribing of controlled drugs. A departmental policy regarding the drugs available within the ED available for dispensing after hours and which may be prescribed on an outpatient basis can give guidance. Approaches vary, but a factual and dispassionate explanation about the inability to prescribe controlled substances due to departmental policy or legal requirements may be of assistance.
The physician needs to determine the appropriateness and utility of an open discussion surrounding the perceived problem behaviour. If open discussion is possible, referral for assistance may be more successful. Opportunities for interdisciplinary discussion of particular patients and an approach to their management with the development of an easily accessible electronically available protocol may assist those in front-line management.
The very important person (VIP)
Essentials
1 Management of the VIP should be based on the maintenance of standard clinical procedures.
2 Management may be aided by the establishment of a plan resembling a disaster plan aimed at coordination of clinical and administrative issues.
3 Specific issues include security, confidentiality and management of the media.
Definition
A VIP in the ED can be defined as anyone whose presence in the ED may, by virtue of the fame or public position, disrupt normal ED functioning [57]. The VIP may be a person of worldwide repute or may also be someone of local fame or importance, such as a prominent staff member. A ‘VIP syndrome’ can occur where the treating staff become so overwhelmed by the person’s presence that they cease to operate in their normal way and the patient’s care is compromised. Disaster plans are formulated in hospitals to deal with situations that overwhelm normal ED operations. In a similar manner, the formulation of a plan to deal with VIPs to ensure optimal management of the patient may help prevent poor outcomes. Ideally, clinical and administrative issues should be individually managed by senior clinical staff.
Management
Medical issues
The key goals of management should be the maintenance of standard clinical procedures. The clinician should perform a standard clinical evaluation without omitting questioning, examinations or procedures that would normally occur due to other considerations, such as embarrassment. Consultation with inpatient specialists should proceed as appropriate and the frequency and timing should reflect standard practice. Deviation from normal procedures, whether in assessment, referral or disposition, invites errors and lack of clarity in management decisions. Healthcare providers function most efficiently when performing their normal roles and nursing staff, junior medical staff and allied health should be involved as appropriate.
Access to the ED should be restricted after the arrival of the patient. Heads of state may be accompanied by their own teams of physicians. The treating clinician should liaise and consult with these physicians when immediate concerns, such as resuscitation, have been addressed.
EDs are accustomed to managing multiple complex patients at once. However, the presence of a VIP may consume the attention of many staff. The senior medical and nursing clinicians need to ensure that adequate staff are assigned to the management of other patients in the ED and that other patients do not suffer adverse outcomes due to the presence of the VIP.
Different issues arise when treating medical colleagues or their families, other staff members or friends and relatives who are ‘relative’ VIPs. While aiming to expedite the management and ensure the comfort of someone who is known to the treating clinician, as with the VIP, the safest pathway for the patients is not to deviate from standard medical care. In general, a conservative clinical approach to the VIP is recommended, with a lower than normal threshold for observation or admission.
Administrative issues
The essential administrative issues are security for the VIP and the hospital staff, protection of privacy and confidentiality, containment of the press, timely release of appropriate information and a coordinated response to the VIP’s needs. If the patient is of national importance, the response may resemble a disaster response and require the appointment of a central coordinator to manage the initial crisis, security control and media liaison [57].
Liaison with hospital security is essential to minimize entry of unnecessary people to the ED and to ensure the safety of the VIP. Assistance from clinical staff may be required to identify those required to enter the ED. Internal security may need to liaise and cooperate with external security teams. The VIP’s security team must not impede medical management.
Confidentiality should be respected and consent to release information should be obtained as with any other patient. Release of information to the media should occur in a graded and accurate manner. Disclosure should occur on two levels: the first is the acknowledgement that the VIP is present and seeking medical attention and the second level involves the graded release of medical information [57]. One senior clinician should be appointed to convey this information. Ideally, a centre for the media should be set up on a site remote from the ED.
While the presence of a VIP in the ED may not overwhelm services in the same way as disaster, a similar approach with a pre-formulated plan of management may assist with the management of these rare and unexpected events and assist in attaining positive outcomes for the VIP and all other patients in the ED.
Controversies and future directions
The development of acute behavioural centres similar to trauma centres may assist in streamlining the management of acute behavioural disturbance.
Given the significant deprivations of rights and liberty that are applied when containing those with behavioural disturbance, there is a need to learn more from patients about their experiences.
The perception of inappropriate ED use by frequent attenders remains controversial, while some healthcare workers and health policy makers continue to assume that frequent attenders can and should be diverted to primary-care providers.
Understanding of drug dependence as a chronic, organic brain disease may reduce stigma and lead to the development of better medical models of treatment that can enhance the behavioural and social therapies currently practised.
References
1. Chamberlain C, MacKenzie D. Understanding contemporary homelessness: issues of definition and meaning. Aust J Social Iss. 1992;27:274–297.
2. Pinkney S, Ewing S. The costs and pathways of homelessness: developing policy-relevant economic analyses for the Australian homelessness service system Melbourne: Institute for Social Research Swinburne University of Technology; 2006; 243.
3. Commonwealth of Australia. The road home: a national approach to reducing homelessness. In: Department of Families H, Community Services and Indigenous Affairs; 2008.
4. Australian Bureau of Statistics. Health and Welfare of Australia’s Aboriginal and Torres Straight Islander peoples, 2008, ABS cat. no. 4704.0. Canberra: Commonwealth of Australia; 2008.
5. Phillips GA, Brophy DS, Weiland TJ, et al. The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department. Med J Aust. 2006;184:602–606.
6. Moore G, Gerdtz M, Manias E, et al. Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery. BMC Public Health. 2007;7:320.
7. Moore G, Hepworth G, Weiland T, et al. Prospective validation of a predictive model that identifies homeless people at risk of re-presentation to the emergency department. Austral Emerg Nurs J. 2012;15:2–13.
8. Haw C, Hawton K, Casey D. Deliberate self-harm patients of no fixed abode: a study of characteristics and subsequent deaths in patients presenting to a general hospital. Soc Psychiatr Psychiatr Epidemiol. 2006;41:918–925.
9. Redelmeier DA, Molin JP, Tibshirani RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345:1131–1134.
10. Australian Bureau of Statistics. Prisoners in Australia, 2010. Canberra; 2010.
11. Department of Justice. Victoria prisoner health study. Melbourne; 2003.
12. Williams BA, Goodwin JS, Baillargeon J, et al. Addressing the aging crisis in U.S criminal justice health care. J Am Geriatr Soc. 2012;60:1150–1156.
13. Kuzak N, O’Connor M, Pickett W, et al. Impact of a prison triage system on injuries seen in emergency departments. Can J Emerg Med. 2001;3:199–204.
14. Hawthorne WB, Folsom DP, Sommerfeld DH, et al. Incarceration among adults who are in the public mental health system: rates, risk factors, and short-term outcomes. Psychiatr Serv. 2012;63:26–32.
15. Patterson RF, Hughes K. Review of completed suicides in the California Department of Corrections and Rehabilitation, 1999 to 2004. Psychiatr Serv. 2008;59:676–682.
16. Augello M. Patients in custody: why do they present to an emergency department? Australasian College for Emergency Medicine (Victorian Faculty) Scientific Meeting. Melbourne 2004.
17. Wakeman SE, Bowman SE, McKenzie M, et al. Preventing death among the recently incarcerated: an argument for naloxone prescription before release. J Addict Dis. 2009;28:124–129.
18. Knott JC, Bennett D, Rawet J, et al. Epidemiology of unarmed threats in the emergency department. Emerg Med Australas. 2005;17:351–358.
19. Phillips G. Senate Select Committee on Mental Health (written and oral submissions) Melbourne: Hansard; 2005.
20. Cannon ME, Sprivulis P, McCarthy J. Restraint practices in Australasian emergency departments. Aust NZ J Psychiatr. 2001;35:464–467.
21. Brookes J, Dunn R. The incidence, severity and nature of violent incidents in the emergency department. Emerg Med (Fremantle). 1997;9:5–9.
22. Emergency Medicine Research Unit Royal Melbourne Hospital. Mental health presentations to the emergency department. Melbourne: Department of Human Services, Victorian State Government; 2006.
23. Australian Federal Government. Senate Select Committee on Mental Health: recommendations; 2006.
24. Parliament of Victoria DaCPC. Inquiry into Violence and Security Arrangments in Victorian Hospitals, recommendations. December 2011.
25. Downes MA, Healy P, Page CB, et al. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21:196–202.
26. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47:79–99.
27. Wallace M. Health care and the law 3rd ed. Sydney: Lawbook Co; 2001.
28. Brayley J, Lange R, Baggoley C, et al. The violence management team An approach to aggressive behaviour in a general hospital. Med J Aust. 1994;161:254–258.
29. Knott J, Taylor D, Castle D. Randomised clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med. 2006;47:61–67.
30. Nobay F, Simon BC, Levitt MA, et al. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11:744–749.
31. Chan EW, Taylor DM, Knott JC, et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61:72–81.
32. Spain D, Crilly J, Whyte I, et al. Safety and effectiveness of high-dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant-affected patients. Emerg Med Australas. 2008;20:112–120.
33. Stratton SJ, Rogers C, Brickett K, et al. Factors associated with sudden death of individuals requiring restraint for excited delirium. Am J Emerg Med. 2001;19:187–191.
34. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med. 2003;24:119–124.
35. Sheline Y, Nelson T. Patient choice: deciding between psychotropic medication and physical restraints in an emergency. Bull Am Acad Psychiatr Law. 1993;21:321–329.
36. Jones J, Lyneham J. Violence: part of the job for Australian nurses? Aust J Adv Nurs. 2000;18:27–32.
37. Jenkins MG, Rocke LG, McNicholl BP, et al. Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and the Republic of Ireland. J Accid Emerg Med. 1998;15:262–265.
38. Wyatt JP, Watt M. Violence towards junior doctors in accident and emergency departments. J Accid Emerg Med. 1995;12:40–42.
39. Gerdtz M, Maude P, Santamaria N, et al. Occupational violence in nursing: an analysis of the phenomenon of code grey/black events in four Victorian hospitals. Published report Melbourne: Policy and Strategic Project Division, Victorian Department of Human Services; 2005.
40. Hunt KA, Weber EJ, Showstack JA, et al. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48:1–8.
41. Jelinek GA, Jiwa M, Gibson NP, et al. Frequent attenders at emergency departments: a linked-data population study of adult patients. Med J Aust. 2008;189:552–556.
42. Byrne M, Murphy AW, Plunkett PK, et al. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med. 2003;41:309–318.
43. Helliwell PE, Hider PN, Ardagh MW. Frequent attenders at Christchurch Hospital’s emergency department. NZ Med J. 2001;114:160–161.
44. Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med. 2000;7 637–6.
45. Hansagi H, Allebeck P, Edhag O, et al. Frequency of emergency department attendances as a predictor of mortality: nine-year follow-up of a population-based cohort. J Publ Hlth Med. 1990;12:39–44.
46. Lucas RH, Sanford SM. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med. 1998;32:563–568.
47. Dent AW, Phillips GA, Chenhall AJ, et al. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med (Fremantle). 2003;15:322–329.
48. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med. 1998;16:648–652.
49. Peddie S, Richardson S, Salt L, et al. Frequent attenders at emergency departments: research regarding the utility of management plans fails to take into account the natural attrition of attendance. NZ Med J. 2011;124:61–66.
50. Moore L, Deehan A, Seed P, et al. Characteristics of frequent attenders in an emergency department: analysis of 1-year attendance data. Emerg Med J. 2009;26:263–267.
51. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J. 2001;18:430–434.
52. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med. 2000;18:603–608.
53. Pope D, Fernandes CM, Bouthillette F, et al. Frequent users of the emergency department: a program to improve care and reduce visits. Can Med Assoc J. 2000;162:1017–1020.
54. World Health Organization. Lexicon of alcohol and drug terms.
55. Weaver M, Schnoll S. Addiction issues in prescribing opioids in chronic non malignant pain. J Addiction Med. 2007;1:2–10.
56. McNabb C, Foot C, Ting J, et al. Profiling patients suspected of drug seeking in an adult emergency department. Emerg Med Australas. 2006;18:131–137.
57. Smith MS, Shesser RF. The emergency care of the VIP patient. N Engl J Med. 1988;319:1421–1423.
21.6 End of life decision making and palliative care
William Lukin, Sandra L Neate and Ben White
Essentials
1 An emergency department attendance represents an opportunity to set goals for care during the attendance and beyond.
2 End of life discussions and advance care planning assist early decision making about treatment goals and end of life care.
3 Knowledge of the law assists decision making at the end of life.
4 Not all dying patients require the skill set of a palliative care specialist but every dying patient will benefit from a palliative approach.
5 Palliative care does not preclude active treatment where the intent is understood by patient and family.
6 Failure to diagnose dying can compromise patient care.
7 The emergency department should foster close relationships with local specialist palliative care providers to improve and ensure timely access for patients and families and so that emergency staff have access to the knowledge and skills provided.
Introduction
Improved socioeconomic conditions and advances in medicine, including improved management of chronic disease, have resulted in extended life expectancy. Prior to death, many people now experience a period of progressive deterioration in health and loss of independence due to complex multisystem disease and possible cognitive impairment. It is estimated that up to 40 000 adult deaths occur in Australia annually in the setting of a medical decision to withhold, limit or withdraw treatment [1]. End of life decision making, such as decisions not to provide, to limit or to discontinue life-sustaining treatments and the decision to transition care to a palliative approach are now a common part of the practice of emergency medicine.
End of life discussions and decision making can be challenging due to the complexity of balancing family wishes with the best interests of the patient and dealing with families in times of great stress. End of life decisions require an understanding of the law and the ethical positions of peak medical bodies and are greatly assisted by patients and their families having considered, discussed and documented their wishes. These discussions and decisions may be communicated informally or formally in advance care plans and directives supported by common law and legislation.
Palliative care is the provision of care to those facing life-limiting or life-threatening illness and focuses on the needs of the patient as a whole across various domains, not just the physical. In addition, it looks at the family as a unit also requiring care. For patients for whom the palliative approach should be adopted, palliative care skills enable the emergency physician to engage patients on a dying trajectory and allow them to take control of this process and plan for the time they have remaining, be it hours, days or months. This enables planning for the non-physical aspects of the dying process and reduces time lost to futile medical endeavours.
The most important aims of end of life discussions and palliative care are the identification of what the patient sees as an acceptable outcome from any proposed treatment, to make early and wise decisions about the appropriateness of treatment and to improve communication with patients and families to enable the provision of patient-centred care [2].
Definitions
Definitions are given in Table 21.6.1.
Table 21.6.1
Definitions of terms
|
Term |
Definition |
|
Advance care planning (ACP) |
A process that allows competent individuals to express their views regarding future healthcare decisions if the capacity to express those views is lost |
|
Advance directive (AD) |
A statement that allows competent individuals to state in advance how they wish to be treated if they lack decision-making capacity in the future. Making an AD can be part of ACP. Different terms are used for ADs in different jurisdictions |
|
Futile treatment |
The definition of futile treatment is contested, but treatment may be considered futile when it is no longer providing a benefit to a patient or the burdens of providing the treatment outweigh the benefits |
|
Good medical practice |
Practice that is consistent with currently recognized medical standards, practices and procedures and currently recognized ethical standards of the medical profession |
|
Life-limiting illness |
An illness where it is expected that death will be a direct consequence of the specified illness |
|
Life-sustaining treatment |
Medical treatment that supplants or maintains the operation of vital bodily functions that are temporarily or permanently incapable of independent operation. This includes assisted ventilation, artificial nutrition and hydration and cardiopulmonary resuscitation but excludes measures of palliative care |
|
Palliative care |
An approach that improves the quality of life for patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and rigorous assessment and treatment of pain and other problems, physical, psychosocial and spiritual |
|
Substitute (surrogate) decision maker (‘person responsible’ in some jurisdictions) |
The person legally responsible for making decisions about healthcare, including its limitations, on behalf of an adult patient who lacks decision-making capacity. State guardianship or medical treatment legislation determines a patient’s substitute decision maker |
|
Enduring guardian, attorney or agent (depending on jurisdiction) |
A substitute decision maker who is given authority by a patient to make healthcare decisions on behalf of that patient if capacity is lost |
General legal principles in end of life decision making
Patients have the right to decide whether to accept or refuse medical treatment. This right is underpinned by Western liberal concepts of self-determination and individual autonomy [3] (see Chapter 25.5). Although the state has an interest in preserving the life and health of citizens, this interest is subject to an individual’s right to self-determination.
Therefore, a patient’s informed consent must be obtained before treatment commences. To perform a medical procedure against the wishes of a patient can amount to trespass and battery in common law and can also contravene guardianship and medical treatment legislation [4]. A legitimate refusal of treatment must be respected, even if it is contrary to medical opinion. Where a person lacks capacity and so cannot give consent, he or she may have an advance directive or consent should be obtained from a legally authorized decision maker, such as a substitute decision maker or parent if the patient is a child.
There are exceptions to the need for consent to treat. One is cases of emergency where both the common law and various legislation (including guardianship legislation) permit the provision of life-saving or other urgent treatment. Another exception is where mental health legislation authorizes treatment [5].
A patient generally has no legally enforceable right to demand a particular treatment. Medical practitioners are not obliged to offer treatment that is not in a patient’s best interests, such as treatments that are futile and where the burdens exceed the benefits of treatment. In Australia, an exception exists under Queensland’s guardianship legislation for adults who lack decision-making capacity as then consent is required to withhold life-sustaining treatment [6].
While the vast majority of disagreements about end of life care are resolved informally, recourse may also be had to the courts and, for adults who lack capacity, to guardianship tribunals and the statutory office of public advocate or guardian.
Expected legal knowledge of medical practitioners
Despite attempts to harmonize the law that regulates end of life decision making, it varies across Australian states and territories [7] and the rest of the world. Medical practitioners play significant legal roles at the end of life including: assessing a patient’s capacity to understand and make decisions for themselves; determining the scope of any consent or refusal and whether it applies to current circumstances; and understanding the operation of guardianship laws to find a patient’s substitute decision maker when the individual is not competent.
Medical practitioners have knowledge gaps regarding their legal roles and obligations [8,9]. The importance of the doctor’s role in ensuring the legality of all decisions and medical treatments and the apparent gap in current knowledge of practitioners suggests that regular systematic legal training for the medical profession would be ideal.
Advance care planning and advance directives
Advance care planning (ACP) is planning and expressing wishes for future health and personal care for a time in the future when the individual cannot make or communicate decisions. ACP provides a means for people to ensure their wishes and preferences are known. Most doctors, nurses and members of the community support ACP but rates of formal planning are low despite evidence that ACP leads to improvement in end of life care, patient and family satisfaction and reduction of anxiety and depression in surviving relatives [10].
Advance directives (ADs) are generally a form of written advance care plan made by a competent person recognized by common law or legislation depending on the jurisdiction. An AD can be written at any time of life and may relate to periods of temporary or permanent incapacity. Content may vary from an expression of personal values and wishes to specific medical directions by a person with a life-limiting illness.
ADs are recognized in many parts of the world, including all Australian jurisdictions and six Australian states and territories now have specific legislation relating to ADs. All jurisdictions, except the Northern Territory, also have legislative provisions that allow patients to appoint a substitute decision maker, called an enduring guardian, enduring attorney or agent depending on the jurisdiction. The guardianship legislation of all states and territories allows for the appointment of a guardian, but this only occurs where less formal mechanisms are inadequate [6].
A National Framework for Advance Care Directives authored by the Clinical, Technical and Ethical Principal Committee of the Australian Health Minister’s Advisory Council aims to provide a practical and ethical basis to the development of a national framework for advanced directives [7].
Limitation or withdrawal of treatment
Emergency medicine practitioners may be confronted with circumstances where the patient and family have not considered the desired outcomes of their ongoing treatment or that death may be a possible outcome of their current condition. Up to 35% of deaths in EDs involve patients in the terminal phases of existing chronic illness who attend the ED for conditions that represent the natural evolution of the illness [11]. The ED has become a place where terminally ill patients frequently die and where decisions regarding limitation or withdrawal of care are now often made.
While doctors generally must not cause or hasten a patient’s death, there are circumstances where limiting or withdrawing treatment is lawful. These include when a competent adult refuses treatment, when another person (such as a substitute decision maker or parent) has lawfully refused treatment on behalf of the patient and when the treatment is not in the patient’s best interests, either because it is considered futile or the burdens are not justified by the potential benefits [4].
The Australian Medical Association states that if a medical practitioner acts in accordance with good medical practice, the following forms of management at the end of life do not constitute euthanasia or physician assisted suicide: not initiating life-prolonging measures; not continuing life-prolonging measures and the administration of treatment or other action intended to relieve symptoms which may have a secondary consequence of hastening death [12].
Despite growing community interest in ADs and an increasing burden of chronic disease, the majority of patients presenting to EDs have not discussed their end of life wishes with family or expressed their wishes in an AD [13]. In these situations, discussions should focus on the desired outcomes of treatment and the delivery of treatments consistent with those desires and which offer some comfort and assistance to the patient.
Resuscitation and not for resuscitation (NFR) orders
When first described in the 1960s, cardiopulmonary resuscitation (CPR) involved simple resuscitative measures to reverse physiological instability. Although CPR can ‘stay’ death on occasion, it is frequently applied in circumstances that will not result in a return to previous health and is applied in patients who are, in reality, dying [14]. American healthcare culture has been described as one of medical optimism, characterized by an unwillingness to give up hope for a miracle, which has led to patients choosing distressing and burdensome treatment options which eventually end in death, whether or not these treatments had been instituted [15]. Unrealistic expectations of outcomes from CPR are common [16].
The combination of knowledge deficits, unrealistic expectations of outcomes and medical optimism have left patients and doctors with a sense that there is a presumed consent to CPR unless otherwise indicated [14]. NFR orders have developed in response to CPR being universally applied and such presumed consent to CPR. The absence of an NFR order has become considered an order to perform CPR unless otherwise instructed [14]. CPR is no longer seen as a medical intervention with specific indications but one of many patient choices.
The American Heart Association defines the goals of resuscitation as to preserve life, restore health, relieve suffering, limit disability and respect the individual’s decisions, rights and privacy [17]. Decisions to commence, continue or to terminate resuscitation are based on the difficult balance between the benefits, risks and cost these interventions place on patient, family members and the healthcare system [18]. Ethical reasons for withholding attempted resuscitation include respecting the patient’s autonomy and choices, weighing maleficence against beneficence (avoiding treatment that may cause more harm than benefit), trying to provide good ‘quality of death’ and the consideration of resources [19].
Some peak medical bodies provide ethical guidance on these issues [17,18,20,21]. The General Medical Council (UK) advises that: ‘in cases where you assess that such treatment is unlikely to be clinically appropriate, you may conclude that CPR should not be attempted’ [22]. The Medical Board of Australia recognizes that: ‘doctors have a vital role in assisting the community to deal with the reality of death and its consequences’ and good medical practice involves both ‘understanding the limits of medicine in prolonging life and recognizing when efforts to prolong life may not benefit the patient’. The Medical Board also states that there is no duty to prolong life at all cost but a duty exists to know when not to initiate and when to cease attempts at prolonging life [23].
The ability to ‘refuse’ an NFR order perpetuates the paradigm that CPR is solely a patient choice and that all deaths can potentially be prevented. The performance of CPR, under the guidance of the bodies such as the GMC and the Medical Board of Australia, is a medical decision that the patient can refuse, but on which the patient cannot insist (although the situation under Queensland’s guardianship legislation discussed above should be noted).
Palliative care
The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families who are living with a life-limiting illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual [24].
Palliative care is an emerging area in emergency medicine with international evidence suggesting that the care of the patient who is imminently dying is not done well in emergency departments. In addition, the care of the patient who is on a dying trajectory who presents to the emergency department needs further research. Palliative care focuses on the needs of the patient as a whole across various domains, not just the physical. In addition, it looks at the family as a unit also requiring care. Emergency physicians should adhere to the principles of a good death for all of the patients who die in emergency departments [25]. For patients for whom the palliative approach should be adopted, skills in palliative care enable the emergency physician to engage patients on a dying trajectory and support them in taking control of this process and putting in place a plan for end of life. This allows for choice of place of death outside of the acute setting, which requires appropriate social and clinical supports. The discussions surrounding such planning include the non-physical aspects of the dying process and may reduce time lost to futile medical endeavours that are likely to ensue in the acute setting.
Specialist palliative care versus a palliative approach
Not all dying patients need the skill set of a specialist palliative care provider. However, all patients living with a life-limiting disease and those dying in the emergency department can benefit from a palliative approach to care. This approach focuses on quality of life remaining for those with life-limiting disease. This approach can be adopted by all clinicians who deal with dying patients. The complexity (in respect to palliation) of a patient fluctuates as the patient approaches end of life. For patients whose needs are complex, timely referral to specialist palliative care providers may be helpful.
Palliative care skills for the emergency physician
Communication skills in the palliative domains (physical, spiritual and psychosocial)
Appropriate discussion around these domains enables patients to regain some control of the dying process and improves the experience for patients and families. While there is often not time for in-depth exploration of all these themes in a patient encounter, simple acknowledgement of their existence by the clinician can help shape the priorities for the presentation. Conversations that begin in the ED can be a stimulus for further discussions with treating teams and also encourage and prompt families to have these discussions. While traditionally viewed as difficult, such discussions are generally welcomed by patients and families. To walk away from a dying patient without this engagement is a failure of care and a loss of opportunity for the patient.
Impeccable assessment skills
The needs of these patients for comprehensive evaluation are the same as any other patient coming into the ED. To deal with physical symptoms appropriately, a diagnosis is required and appropriate investigations may be undertaken if there is likely to be a benefit. For example, delirium in an older person may be relatively simply resolved through appropriate investigation and treatment of the underlying cause and should not be ignored or generically treated with sedation.
Pain relief and symptom control
Uncontrolled pain or other distressing symptoms may prevent engagement in appropriate end of life discussions and planning. It is imperative that these needs be met promptly in the ED. Where these needs are complex, early referral to specialist palliative care providers may assist. No patient should have uncontrolled pain in an ED and processes should address this with pain score assessments, protocol-driven analgesia and fostering a culture where patients and families can speak up and voice concern. For patients under the active care of palliative providers who are on opioid analgesics other than morphine, understanding the relative potency of these opioids is critical to providing appropriate titration of medication in the ED.
Diagnosing dying
The concept of diagnosing dying implies recognition of the fact that the patient will not recover from a given illness. The need for this emphasis stems from our place in a society that denies death and an acute care system that can see death as the enemy. Failure to diagnose the dying process can result in over-investigation, inappropriate treatment and instillation of false hope and shortens the time dying patients have to plan for what is to come. A simple question often posed by palliative care providers is ‘Would you be surprised if your patient were to die in the next 12 months?’ For emergency clinicians it could be posed as ‘Would you be surprised if this patient died during this admission?’ If the answer is ‘no’ to the ‘surprise question’, then there is an opportunity to engage patients and families in discussions about the goals of this admission. Referral to palliative care providers from the ED can shorten length of stay in hospital and increase the likelihood that goals of care around end of life care are established. This reduces the burden on the medical emergency response teams within the hospital.
The dying pathway
For patients whose death is imminent (hours), it may not be appropriate to transfer them out of the emergency department. In this case, compassionate, understanding care is necessary, perhaps involving the use of a clinical pathway, such as the Liverpool care pathway [26], that enables hospice level care to be delivered in other care settings, such as a short-stay unit. The use of continuously delivered medication via syringe driver may be appropriate in this setting to control pain and other symptoms.
The role of the medical practitioner in end of life care
The Australian Medical Association states that good quality end of life care should ensure that the patient is treated with respect, dignity and compassion and is free from unnecessary suffering; should be treated in their environment of choice; that goals for end of life care, privacy and confidentiality are respected; that the physical, psychological, emotional, religious and spiritual needs of the patient, their family and carers are supported; patients and family members are encouraged, where appropriate, to participate in managing their treatment; and that counselling and other support are provided throughout the patient’s condition and beyond the patient’s death [12].
The provision of high quality end of life care requires early discussions and planning with the patient and family so that all concerned with the patient’s care are clear about the goals of treatment. Silvester identifies three opportunities to ensure that patient-centred care is delivered at the end of life [27]. First, a competent person may consider and express their wishes via advance care planning. Second, when a person is no longer competent, healthcare professionals should determine whether advance directives exist and have discussions with substitute decision makers about what outcome the patient would have wished. Third, the delivery of care at the end of life should provide a ‘good death’: avoiding suffering and the prolongation of dying, achieving a sense of control, relieving burdens placed on the family and strengthening relationships with loved ones.
Controversies and future directions
Close partnering between emergency providers and palliative care providers will provide timely intervention in the emergency departments so that opportunities to establish goals of care are not lost.
Short-stay units should be able to provide hospice level care to the dying with support as required from specialist palliative care services or the use of care of the dying pathways.
End of life and palliative care may become subspecialty areas for emergency physicians.
Short-stay units may incorporate palliative care beds for the care of those imminently dying in whom transfer may be impractical.
Acknowledgements
Thanks to Dr Carol Douglas, Director Palliative Care Royal Brisbane and Women’s Hospital, for her suggestions.
References
1. White B, Willmott L, Trowse P, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: Part 1 (New South Wales). J Law Med. 2011;18:498–522.
2. Cartwright CM, Parker MH. Advance care planning and end of life decision-making. Aust Fam Phys. 2004;33:815–819.
3. Willmott L, White B, Mathews B. Law, autonomy and advance directives. J Law Med. 2010;18:366–389.
4. Skene L. Law and medical practice–rights, duties, claims and defences, 3rd ed. Australia; 2008.
5. Ryan CJ, Callaghan S. Legal and ethical aspects of refusing medical treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust. 2010;193:239–242.
6. White B, McDonald L, Willmott L. Health law in Australia Sydney: Thomson Reuters; 2010.
7. Australian Health Minister’s Advisory Council. A National Framework for Advance Care Directives; 2011.
8. Willmott L, White B, Parker M, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: Part 2 (Queensland). J Law Med. 2011;18:523–544.
9. Willmott L, White B, Parker M, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: Part 3 (Victoria). J Law Med. 2011;18:773–797.
10. Detering KM, Hancock AD, Reade MC, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. Br Med J. 2010;340:c1345.
11. Tardy B, Venet C, Zeni F, et al. Death of terminally ill patients on a stretcher in the emergency department: a French speciality? Intensive Care Med. 2002;28:1625–1628.
12. Australian Medical Association. The role of the medical practitioner in end of life care; 2007.
13. Le Conte P, Riochet D, Batard E, et al. Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support. Intens Care Med. 2010;36:765–772.
14. Bishop JP, Brothers KB, Perry JE, et al. Reviving the conversation around CPR/DNR. Am J Bioeth. 2010;10:61–67.
15. Scripko PD, Greer DM. Practical considerations for reviving the CPR/DNR conversation. Am J Bioeth. 2010;10:74–75.
16. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35:338–342.
17. Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675.
18. Lippert FK, Raffay V, Georgiou M, et al. European Resuscitation Council Guidelines for Resuscitation 2010: Section 10 The ethics of resuscitation and end-of-life decisions. Resuscitation 2010.
19. Fritz Z, Fuld J. Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects. J Med Ethics. 2010;36:593–597.
20. American College of Emergency Physicians. Ethical issues at the end of life. Ann Emerg Med 2008; 52:592–3.
21. American College of Emergency Physicians. Ethical issues of resuscitation. Ann Emerg Med 2008; 52:593.
22. General Medical Councilend of life care. When to consider making a Do Not Attempt CPR (DNACPR) decision London: General Medical Council; 2010.
23. Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. Australia.
24. World Health Organization. Cancer. Palliative care; 2012.
25. Ellershaw J, Dewar S, Murphy D. Achieving a good death for all. Br Med J. 2010;341:c4861.
26. The Marie Curie Palliative Care Institute. Liverpool care pathway for the dying patient; 2012.
27. Silvester W, Detering K. Advance care planning and end-of-life care. Med J Aust. 2011;195(8):435–436.
21.7 Organ and tissue donation
Sandra L Neate and David Pilcher
Essentials
1 Significant numbers of missed potential organ and tissue donors have been identified in emergency departments and intensive care units.
2 Clinical triggers have been introduced in Australian emergency departments to assist with early identification of potential donors.
3 Knowledge of pathways to donation and the skills required to commence donation discussions may decrease the numbers of missed potential donors and improve the numbers of organ and tissue donors.
Introduction
Transplantation has become the therapy of choice for patients with end-stage organ failure. However, worldwide, there are insufficient organs available to meet demand for those on transplantation waiting lists. In Australia in 2012, there were 1600 people awaiting organ transplantation. In 2011, there were 337 deceased organ donors in Australia and 1001 transplant recipients [1]. Between 2008 and 2011, 474 patients were admitted to Australian and New Zealand intensive care units (ICUs) primarily to assess suitability for organ donation and, of these, almost two-thirds came directly from the emergency department (ED) [2].
In Australia, there is a relatively small pool of potential donors [3], as less than 2% of patients who die in hospital are eligible to donate their organs. However, there is potential to increase the number of organ donors. Despite high rates of community support for donation, consent rates to donation by families of donor- eligible patients remain a major limiting factor to donation [4]. In Australia, fewer than 60% of families consent to donation. Another factor limiting donation rates is missing opportunities for donation. Missed opportunities include situations where life-sustaining therapies are withdrawn in patients with imminent or potential brain death, particularly in the ED; patients who may be suitable for donation for whom donation is never raised due to clinician unwillingness to discuss donation with family; resource pressures; and a perception by clinicians that the patient may not be medically suitable for donation [5,6].
Although donation of solid organs is a rare opportunity, eye and tissue (e.g. skin, bone, heart valves and connective tissues) donation can occur up to 24 hours after death regardless of where death occurred and may apply to a larger population of patients, especially those in the ED.
Emergency practitioners play an important role in the donation process. Donors identified in the ED, although small in number, have a greater rate of proceeding to successful donation than those referred from other in-patient critical care settings [7]. Emergency clinicians are ideally placed to exhibit positive attitudes toward donation, support donation, identify potential donors and assist families to make informed decisions about donation.
Donation pathways
The initial critical step in making organ donation a reality is to recognize the potential donor. These are usually ventilated patients in the ED or ICU who are expected to die either through brain death or following cessation of the circulation. The majority of donations in Australia and worldwide occur following brain death. The donation of heart, lungs, liver, pancreas, bowel and kidneys from one brain dead donor can lead to up to eight organ transplants. For a minority of patients, donation may be possible when death is diagnosed after cessation of the circulation. This is known as donation after cardiac (or circulatory) death (DCD) or non-heart beating donation and may lead to the donation of kidneys, lungs or liver but rarely other organs. Kidneys are the only organs donated commonly from living donors, although lobar liver and lung donation has occasionally been performed.
Donation after brain death (DBD)
Criteria to diagnose brain death vary slightly in different countries [8,9] but essentially depend on the loss of capacity for consciousness and the ability to breathe. If certain preconditions are met (e.g. no effects of sedating drugs and a diagnosis consistent with producing severe brain injury), brain death may be diagnosed clinically by demonstrating loss of all brainstem reflexes. Making a clinical diagnosis of brain death cannot be done until a period of observation has elapsed (minimum 4 hours in Australia). Thus, brain death is rarely diagnosed in the ED, but patients who might become brain dead are commonly identified here. When clinical testing is not possible, imaging tests (e.g. cerebral angiograms, nuclear medicine scans and computed tomography (CT) angiogram) may be performed.
Donation after cardiac death
Although donation after brain death has remained the most common route for organ donation throughout the world, the 2000s saw renewed interest in achieving donation from patients in whom death was diagnosed after cessation of circulation. Unlike brain dead donation, the practices and processes for DCD vary widely across countries and reflect differing social, medical and legal environments. Patients considered for DCD in Spain and France are those who present following cardiac arrest (with or without failed attempts at resuscitation) – so-called ‘uncontrolled DCD’. In contrast, in Australia, the UK and the USA, DCD is usually performed in patients who undergo elective withdrawal of cardiorespiratory support in ICU after determining that a person will not recover – so-called ‘controlled DCD’ [10]. DCD has been increasingly implemented across Australia and has led to an increase in overall donor numbers and organs transplanted without a reduction in brain dead donors. The widespread implementation of DCD across Australia may help reduce the shortfall of organs for transplantation [11].
Introducing uncontrolled DCD to emergency departments
The recognition that patients who died following cardiac arrest might still be suitable donors has led to the creation of ‘rapid response teams’ or ‘mobile donor units’ to facilitate organ donation when such patients are identified either within the ED or prior to admission to hospital. These have resulted in successful donations in Spain, France, Japan and the USA. However, some programmes started in the USA have closed down due to a failure to identify more than a handful of patients [12]. In addition, concerns over the use of vascular cannulation techniques for organ perfusion which are similar to extra-corporeal membrane oxygenation – cardiopulmonary resuscitation (ECMO–CPR), lack of consistency over an appropriate observation period (‘hands-off’ time) prior to instituting organ preservation therapy (varying from 2 minutes in some US states to 20 minutes in Italy) and the large resources required for small numbers of suitable patients [13], are likely to limit uptake of these techniques outside a few specialized centres worldwide.
Initiatives to improve organ donation rates
There is wide variation in rates of organ donation throughout the world with Spain’s 30+donors per million population often highlighted as a target for others. Many factors influence these numbers, including the number of road traffic fatalities, attitudes towards ongoing treatment of patients who are going to die but in whom wishes about donation are not known, access to intensive care beds (lower in the UK than in Spain and Australia), end of life practices in general and public support for organ donation among others. However, countries that have successfully increased donation rates have concerted approaches towards identification of potential donors, support for clinicians involved in donation, pubic promotion about the benefits of organ donation and transplantation, clear legislation, infrastructure and funding.
In the late 1980s and early 1990s, Spain established a system of transplant donor coordinators (predominantly doctors supported by specialized nurses) in all major hospitals. It was only with the implementation of this system (a decade after Spain’s presumed consent laws) that the major increase in Spain’s donation rates occurred. The USA has a long history of federal legislation which supported the creation of the united network for organ sharing (UNOS) which coordinates 11 different organ procurement organizations (OPOs) [14].
For many years, Australia’s donation rate lagged a long way behind that of similar developed countries. In the late 2000s, building on experiences from abroad, federal funding of over $150 million led to the formation of the Australian Organ and Tissue Donation and Transplantation Authority and thus a coordinated national approach to increasing organ donation. This has led to a progressive increase in donor numbers to 15 per million population in 2011, from below 10 per million in 2000 [15]. One of the key strategies has been to focus on identification of the potential donor. Recognizing that nearly half of the unrecognized potential brain dead donors died in the ED [3], clinical triggers have been adopted in the ED and ICU.
Clinical triggers for identification of potential donors
Clinical triggers have been developed worldwide and aim to minimize the number of missed potential donors, particularly those in whom life-sustaining therapies are withdrawn in the ED and ICU who would be likely to progress to brain death if supportive treatment was continued [3].
In the UK, the National Institute for Health and Clinical Excellence has published guidelines for the identification of potential DBD and DCD donors [16]. In the USA, the use of clinical triggers that utilize clinical signs suggestive of irrecoverable brain injury or where withdrawal of life-sustaining therapies is being considered, assist the identification and (often mandatory) referral of patients to OPOs.
In Australia, the GIVE clinical trigger was introduced in 2010. The trigger aims to identify patients with a Glasgow coma scale (GCS) equal to or less than 5 (G) from an irrecoverable brain injury who are intubated (I), ventilated (V) and in whom withdrawal of life-sustaining measures and end of life care (E) is being discussed. It is important to note that there are no medical exclusions to activation of the trigger. Following identification of a potential donor and discussions with families regarding consideration of their family member’s wishes, admission to the ICU can be undertaken to continue the assessment of the potential for organ and tissue donation (OTD).
With the increasing availability of DCD, it is worth remembering that missed opportunities may also occur in patients who do not fit the clinical triggers exactly as implemented in Australia or elsewhere. Although the majority of potential DCD patients are those with a low GCS due to neurological injuries, patients about to undergo withdrawal of cardiorespiratory support following terminal heart or lung disease may still be liver or kidney donors. Education and training in donor recognition, referral pathways and in OTD is vital to ensure patients such as these can be given the opportunity to be organ donors. This is known to increase rates of successful donation and the comfort and competence of practitioners and is supported by the public within Australia [17,18].
Emergency clinicians attitudes to, knowledge and perceptions of OTD
An Australian survey of ED clinicians showed high levels of general support for OTD, a willingness to donate their own organs and tissues after death and to consent to OTD of family members [19]. In general, ED clinicians agree that facilitation of OTD is a vital part of emergency medicine [20] but that barriers exist to facilitation, such as time, resource pressures and access block [21]. Resources in EDs may pose a barrier to the facilitation of OTD. Most EDs operate at full capacity with time pressures limiting time available for complex discussions with families and continued support of the potential donor if ICU facilities are not immediately available. Hospital overcrowding compounds the problem. Imposed performance indicators requiring a definitive destination for patients within 4 hours may also compound perceived and real barriers [21].
Cultural and religious barriers to facilitation of OTD exist both with respect to the clinician’s comfort in discussing and facilitating OTD [19] and to family acceptance of and consent to donation. Despite common perceptions, most religions, including all major religions, support OTD and transplantation as acts of generosity and merit because they benefit others [22]. Early consultation with religious elders may assist if families express concerns.
Attitudes of healthcare providers to OTD are known to affect the outcome of donation-related conversations, with this effect extending even to the perceived level of care and concern displayed by treating physicians, independent of any discussions around donation [4,23].
The acceptance of brain death as a valid determination of death is essential for clinician support of OTD. While acceptance of brain death is high among emergency clinicians, some knowledge deficits about brain death exist [24]. While it is uncommon for emergency clinicians to need to explain brain death and very rare to have to assist in determination of brain death, understanding brain death assists both the clinician and family.
OTD discussions in the ED
Discussions with families about OTD in the ED may arise infrequently for the individual practitioner, but knowledge of donation pathways and expertise in communication ensures accurate information is imparted to families to enable informed decision making when the occasion arises. With growing public education about OTD, families may raise OTD or discussions may be required following activation of clinical triggers in end of life discussions. Depending on pathways within hospitals, specialists in donation discussions may be available to talk with families, but this may not be the case in many environments.
Enhanced knowledge and experience with OTD-related tasks increase comfort and competence in organ donation discussions [18]. Specific training in donation conversations and related communication skills and behaviours increase the clinician’s comfort in speaking with patients’ families about donation and answering donation-related questions and consent to both organ donation [25] and tissue donation following death [26].
As with all aspects of end of life communication, normalization of the discussion of OTD assists both the clinician and the family in feeling comfortable about such discussions. The offer of OTD as a routine part of end of life care, when appropriate, can assist families and clinicians in this respect. Failing to offer donation to families may result in families feeling they were unable to fulfil their loved one’s wishes in the future. The offer of OTD may also offer the possibility for converting an otherwise negative discussion and circumstance into a discussion with a potentially positive outcome for the family.
An understanding of the common factors influencing decisions regarding OTD may assist practitioners in delivering factual information that can address concerns and support the family’s right to make a choice that is based on complete information [27]. Families cannot make informed choices when the information they receive is incomplete and this information may include the potential benefits of OTD to others. Reasons that families support donation in principle and consent to donation include altruism; the positive impact that donation will make on others’ lives; pre-existing knowledge of their loved one’s wishes; and the solace which may be derived from organ donation. Reasons given for not supporting donation and non-consent to donation include fear of disfigurement; the belief the body must be buried whole; fear of medical neglect of potential donors; religious concerns; and not knowing the family member’s wishes [4,28,29].
The aim of ED discussions regarding organ donation is not to obtain formal consent to donation, as this is would be premature in the ED setting. The aim is to offer donation as one of the possibilities that may be considered at the end of life, in a patient who may have the potential to become an organ donor. Following the identification of a potential donor and the discussion of the possibility of donation in the end of life setting with the family, early involvement of intensive care specialists and then donation agency staff to continue donation discussions should occur.
Eye and tissue donation
The donation of tissues, such as eye and corneal tissue, musculoskeletal tissues including bone, tendons and menisci, cardiac tissue including heart valves and pericardium and skin tissues, can both enhance and save lives, for example by restoring vision, improving mobility, replacing diseased heart valves and as skin grafts in burns victims [30].
Tissue donation can occur following death, independent of the donation of solid organs and the place of death. Unlike solid organ donation, the patient does not need to be managed in an ICU setting prior to donation. Patients who die in the ED commonly have fewer exclusions to the donation of eyes and tissues (e.g. sepsis, massive blood product transfusion). However, the current rates of tissue donation are paradoxically low given that the pool of potential tissue-eligible donors is much larger than the potential solid organ donor pool.
Community awareness of eye and tissue donation may be less than that of solid organ donation. Because many families have limited knowledge about tissue donation, the knowledge and communication skills of the clinician may affect the next of kin’s perceptions of donation and thus affect the likelihood of consent to donation [31]. The knowledge and communication skills that affect organ donation discussions also affect the discussion regarding eye and tissue donation [25]. Quality of communication skills and the level of comfort of the requester are known to affect outcome of these discussions just as they do for organ donation[26].
In some jurisdictions in the USA, reporting of hospital deaths to OPOs is mandated in law. The family of every deceased patient who may be considered a potential eye and tissue donor will be approached by phone by an OPO. In Australia, consideration of the potential for eye and tissue donation rests, in general, with the treating clinician and the discussion with families regarding potential tissue donation should ideally be part of routine end of life care. Eye donation can frequently occur on the hospital premises. Tissue retrieval often needs to occur in a controlled environment within 24 hours of death, so identification of potential donors, discussion with families and notification of eye and tissue donation agencies must occur in a timely fashion.
Controversies and future directions
With the increasing frequency of DCD, clinical triggers for the identification of potential donors may need to be extended to include all those in whom withdrawal of life-sustaining therapies is being considered.
Although the number of donors from patients presenting to EDs in cardiac arrest is low, this is an ongoing area of research and interest.
Rates of eye and tissue donation could be increased by identification of potential tissue donors in the ED.
Acknowledgements
Thanks to Stefan Poniatowski, Head, Donor Tissue Bank of Victoria, for advice regarding eye and tissue donation.
References
1. Organ and Tissue Authority. Performance Report 2011: Australian Government Organ and Tissue Authority; 2011.
2. ANZICS Centre for Outcome and Resource Evaluation. ANZICS Adult Patient Database. Carlton, Victoria.
3. Opdam HI, Silvester W. Potential for organ donation in Victoria: an audit of hospital deaths. Med J Aust. 2006;185:250–254.
4. Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation. J Am Med Assoc. 2001;286:71–77.
5. Aubrey P, Arber S, Tyler M. The organ donor crisis: the missed organ donor potential from the accident and emergency departments. Transplant Proc. 2008;40:1008–1011.
6. Riker RR, White BW. Organ and tissue donation from the emergency department. J Emerg Med. 1991;9:405–410.
7. Michael GE, O’Connor RE. The importance of emergency medicine in organ donation: successful donation is more likely when potential donors are referred from the emergency department. Acad Emerg Med. 2009;16:850–858.
8. Australian and New Zew Zealand Intensive Care Society. The ANZICS Statement on Death and Organ Donation. 3.1 edn. Melbourne; 2010.
9. Gardiner D, Shemie S, Manara A, Opdam H. International perspective on the diagnosis of death. Br J Anaesth. 2012;108(Suppl 1):i14–i28.
10. Manara AR, Murphy PG, O’Callaghan G. Donation after circulatory death. Br J Anaesth. 2012;108(Suppl 1):i108–i121.
11. Coulson TG, Pilcher DV, Graham SM, et al. Single-centre experience of donation after cardiac death. Med J Aust. 2012;197:166–169.
12. Green J. Organ donation in the emergency department A missed opportunity? Ann Emerg Med 2012;59.
13. Blackstock M, McKeown DW, Ray DC. Controlled organ donation after cardiac death: potential donors in the emergency department. Transplantation. 2010;89:1149–1153.
14. Rudge C, Matesanz R, Delmonico FL, Chapman J. International practices of organ donation. Br J Anaesth. 2012;108(Suppl 1):i48–i55.
15. Australia and New Zealand Dialysis and Transplant Registry. Australia and New Zealand Organ Donation Registry 2012 Report; 2012.
16. National Institute for Health and Clinical Excellence. CG 135 Organ donation: identification and referral of potential organ donors; 2012.
17. Riker RR, White BW. The effect of physician education on the rates of donation request and tissue donation. Transplantation. 1995;59:880–884.
18. Neate S, Marck CH, Weiland TJ, et al. Australian emergency clinicians’ perceptions and use of the GIVE clinical trigger for identification of potential organ and tissue donors. Emerg Med Australas. 2012;24:501–509.
19. Marck CH, Weiland TJ, Neate SL. Personal attitudes and beliefs regarding organ and tissue donation: a cross-sectional survey of Australian emergency department clinicians. Prog Transplant. 2012;22:317–322.
20. Jelinek GA, Marck CH, Weiland TJ. Organ and tissue donation-related attitudes, education and practices of emergency department clinicians in Australia. Emerg Med Australas. 2012;24:244–250.
21. Marck CH, Jelinek GA, Neate SL, et al. Resource barriers to the facilitation of organ and tissue donation reported by Australian emergency clinicians. Australian health review: Australian Hospital Association; 2012.
22. Organ and Tissue Authority. Religion and donation. Canberra; 2012.
23. Siminoff LA, Arnold RM, Hewlett J. The process of organ donation and its effect on consent. Clin Transplant. 2001;15:39–47.
24. Marck CH, Weiland TJ, Neate SL. Australian emergency doctors’ and nurses’ acceptance and knowledge regarding brain death: a national survey. Clin Transplant. 2012;26:E254–E260.
25. Siminoff LA, Marshall HM, Dumenci L. Communicating effectively about donation: an educational intervention to increase consent to donation. Prog Transplant. 2009;19:35–43.
26. Siminoff LA, Traino HM, Gordon N. Determinants of family consent to tissue donation. J Trauma. 2010;69:956–963.
27. Mulvania P, Wise C. Dual advocacy: a value-positive approach to obtaining consent for organ donation Philadelphia: Gift of Life Institute training material; 2012.
28. Irving MJ, Tong A, Jan S, et al. Community attitudes to deceased organ donation: a focus group study. Transplantation. 2012;93:1064–1069.
29. Siminoff L, Mercer MB, Graham G, Burant C. The reasons families donate organs for transplantation: implications for policy and practice. J Trauma. 2007;62:969–978.
30. Siminoff LA, Traino HM, Gordon NH. An exploratory study of relational, persuasive, and nonverbal communication in requests for tissue donation. J Hlth Commun. 2011;16:955–975.
31. Dorflinger L, Auerbach SM, Siminoff LA. The interpersonal process in tissue donation requests with “undecided” next of kin. Prog Transplant. 2012;22:427–435.