The participants in the investigation of SPCS reported it to be an important structure in the care of palliative emergencies in a home-care setting [1–4]. In many countries, this structure is still in need of development and expansion (for example, where there is a lack of financing or not enough qualified personnel for its implementation) .
In our research, we were able to show that the experts questioned were aware of the above-mentioned problem and that a demand for SPCS exists. Furthermore, the strengthening of cooperation between SPCS, general practitioners, and prehospital emergency medical staff is recommended [4, 18, 19]. This was previously recommended in an Australian review paper in 2003 . This collaboration is important because of the limited exposure to their family physicians of patients who are in a palliative care situation and or in advanced stage of their disease . The specialised support offered by PCTs is regarded to be necessary . Further work provides evidence that patients in a palliative care situation who receive PCT rarely use emergency medical structures . According to the results of our research, the development and improvement of the SPCS structure and the expansion of outpatient palliative medical basic care is the most effective way to reduce emergency medical treatment for outpatient patients in a palliative care situation. Unfortunately, the results of the present investigation describe problems in the provision of good palliative care and the treatment of palliative emergencies that are already relatively well known. Nevertheless, this type of care should be practiced, although it is currently practiced in all of the included countries.
The reply rate of the experts who were questioned was very high and detailed, particularly because of the questionnaire’s open response options. The care of patients in a palliative care situation at the end of life has different structural requirements for multiple professions [18, 20, 21]. Our research presents international recommendations for the structural cooperation between palliative and emergency medical care [18, 22–24].
The following section discusses a way to optimise the care of patients in a palliative care situation in an outpatient emergency setting using the available systems and represents the recommendations of the experts that we questioned.
The extension of SPCS and basic palliative care structures [4, 25, 26].
The additional integration of outpatient SPCS into the emergency care provided by the emergency medical service, thus ensuring available outpatient care [25, 26].
Improvement in the communication and cooperation between PCT and emergency medical services [25, 26].
Enhancement of the medical education of emergency medical staff [14, 15, 22, 23].
Early implementation of “End-of-Life” conversations to define a palliative care patient [27–29].
Generating the patient’s advance directive for specific palliative emergencies [20, 21, 28].
Preparing trusted family caregivers, outpatient nursing service and nursing homes for palliative emergencies and constructing emergency plans for their use [4, 9, 18, 30].
Distribution of emergency drug boxes that can be used independently by all persons who are integrated into the care of the patient .
Integration of palliative care and ethical competence into Intensive Care Units und Emergency Departments [3, 32–34].
It is also important to note here the existence of relevant worldwide differences in emergency systems that can be significant in the care of patients in a palliative care setting who are in acute emergency situations . These differences were noted by the experts questioned and would be partially integrated into outpatient palliative care. Experts, particularly in countries with paramedic-based emergency systems, recommended physician-supported SPCS. The possible disadvantage of a paramedic-based emergency system was described in the literature, particularly in regard to DNAR orders. In this context, clear differences, also within the different paramedic-based emergency systems, were reported. The objective of this research was not to assess the different emergency medical care systems. However, in the future it may be helpful to discuss possible general problems in the care of outpatient palliative care patients in acute emergency situations on the basis of functioning emergency medical systems and suggest possible solutions. Furthermore, it may be necessary to define general problems that may arise in the care of outpatient palliative care patients in emergency situations, or palliative emergencies, on the basis of the reported international systems and to suggest possible solutions.
Limitations of the study
Our investigation has a number of limitations. The interview design was a substantial limitation. The closed-question section of the interview did not include all of the same aspects as the open-question section. Furthermore, there is no clear consensus on how to report and analyse Likert responses. Our report only considers the recommendations that were voluntarily reported. However, options from many of the experts who responded to the interview questions were of use for our study. In the search for experts with published articles that were considered relevant to palliative care and emergency medical care, the goal was to obtain their opinions on nationally and regionally recommended concepts. We must also mention that it is questionable whether the selected experts’ opinions are representative because the questions were addressed only by experts in their fields. This may be a potential bias of our investigation. It is likely that experts who have published papers are aware of aspects of excellence in their local service provision. Representatives of national organisations may not be aware of these local developments, but they will be aware of national perspectives and drivers of change, bringing different strengths and perspectives to the questions. However, these limitations did not alter the objectives of our study. Many of the answers and recommendations that were volunteered by the experts were significantly evaluated and could be considered independently of their frequent reporting in the development of an optimal outpatient palliative medical care model for emergency situations. Another limitation is the focus on experts from Europe and the USA. Countries that have varied health care policies and palliative care structures can only benefit to a limited extent from the discussions of the development and optimisation of outpatient palliative medical emergency structures. There may be a “continent effect” in our investigation. However, the direct comparisons of the results between different countries are challenging because the methods used were not sufficiently similar, and most medical systems were restricted to particular specialties or specific palliative care systems. The purpose of our study was not to establish a worldwide standard to treat palliative emergencies but to determine different possibilities for functioning outpatient palliative medical emergency structures and to discuss their approaches in general. Finally, the implementation of these ideas is the responsibility of the individual countries, independent of their existing health care policies, structures and potentials.