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Mariolis T, McKew C. Using Simulation to Improve Care of the Critically Ill Mental Health Patient at the End of Life. Nurs Educ Perspect 2020; 41:52-53. [PMID: 31860490 DOI: 10.1097/01.nep.0000000000000426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article summarizes a pilot simulation using standardized patients that was designed to develop skills necessary to care for the critically ill mental health patient nearing the end of life. Although the simulation was found to be a valuable teaching strategy, additional research, with a rigorous design, is recommended to further develop this teaching method. The authors suggest adopting a theoretical framework for debriefing that would elicit emotions, address the emotional needs of students, and assist them to develop coping strategies and skills necessary to care for patients at the end of life.
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Strautmann A, Allers K, Fassmer AM, Hoffmann F. Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey. BMC Palliat Care 2020; 19:2. [PMID: 31900141 PMCID: PMC6942381 DOI: 10.1186/s12904-019-0512-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.
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Luth EA, Pristavec T. Do Caregiver Experiences Shape End-of-Life Care Perceptions? Burden, Benefits, and Care Quality Assessment. J Pain Symptom Manage 2020; 59:77-85. [PMID: 31419541 PMCID: PMC6942199 DOI: 10.1016/j.jpainsymman.2019.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Researchers, hospices, and government agencies administer standardized questionnaires to caregivers for assessing end-of-life care quality. Caregiving experiences may influence end-of-life care quality reports, which have implications for caregiver outcomes, and are a clinical and policy priority. OBJECTIVES This study aims to determine whether and how caregivers' end-of-life care assessments depend on their burden and benefit perceptions. METHODS This study analyzes data from 391 caregivers in the 2011 National Study of Caregiving and their Medicare beneficiary care recipients from the 2011-2016 National Health and Aging Trends Study. Caregivers assessed five end-of-life care aspects for decedents. Logistic regression was used and predicted probabilities of caregivers positively or negatively assessing end-of-life care based on their burden and benefit experiences calculated. Analyses adjusted for caregiver and care recipient demographic and health characteristics. RESULTS No or minimal caregiving burden is associated with ≥0.70 probability of caregivers reporting they were always informed about the recipient's condition and that the dying person's care needs were always met, regardless of perceived benefits. High perceived caregiving benefit is associated with ≥0.80 probability of giving such reports, even when perceiving high burden. CONCLUSION Caregiver burden and benefit operate alongside one another regarding two end-of-life care evaluations, even when years elapse between caregiver experience reports and care recipient death. This suggests that caregiver interventions reducing burden and bolstering benefits may have a positive and lasting impact on end-of-life care assessments.
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Piamjariyakul U, Petitte T, Smothers A, Wen S, Morrissey E, Young S, Sokos G, Moss AH, Smith CE. Study protocol of coaching end-of-life palliative care for advanced heart failure patients and their family caregivers in rural appalachia: a randomized controlled trial. BMC Palliat Care 2019; 18:119. [PMID: 31884945 PMCID: PMC6936135 DOI: 10.1186/s12904-019-0500-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/04/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Heart failure (HF) afflicts 6.5 million Americans with devastating consequences to patients and their family caregivers. Families are rarely prepared for worsening HF and are not informed about end-of-life and palliative care (EOLPC) conservative comfort options especially during the end stage. West Virginia (WV) has the highest rate of HF deaths in the U.S. where 14% of the population over 65 years have HF. Thus, there is a need to investigate a new family EOLPC intervention (FamPALcare), where nurses coach family-managed advanced HF care at home. METHODS This study uses a randomized controlled trial (RCT) design stratified by gender to determine any differences in the FamPALcare HF patients and their family caregiver outcomes versus standard care group outcomes (N = 72). Aim 1 is to test the FamPALcare nursing care intervention with patients and family members managing home supportive EOLPC for advanced HF. Aim 2 is to assess implementation of the FamPALcare intervention and research procedures for subsequent clinical trials. Intervention group will receive routine standard care, plus 5-weekly FamPALcare intervention delivered by community-based nurses. The intervention sessions involve coaching patients and family caregivers in advanced HF home care and supporting EOLPC discussions based on patients' preferences. Data are collected at baseline, 3, and 6 months. Recruitment is from sites affiliated with a large regional hospital in WV and community centers across the state. DISCUSSION The outcomes of this clinical trial will result in new knowledge on coaching techniques for EOLPC and approaches to palliative and end-of-life rural home care. The HF population in WV will benefit from a reduction in suffering from the most common advanced HF symptoms, selecting their preferred EOLPC care options, determining their advance directives, and increasing skills and resources for advanced HF home care. The study will provide a long-term collaboration with rural community leaders, and collection of data on the implementation and research procedures for a subsequent large multi-site clinical trial of the FamPALcare intervention. Multidisciplinary students have opportunity to engage in the research process. TRIAL REGISTRATION ClinicalTrials.gov NCT04153890, Registered on 4 November 2019.
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Irajpour A, Hashemi M, Taleghani F. The quality of guidelines on the end-of-life care: a systematic quality appraisal using AGREE II instrument. Support Care Cancer 2019; 28:1555-1561. [PMID: 31834517 DOI: 10.1007/s00520-019-05220-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 11/28/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines are intended to facilitate knowledge translation and evidence-based clinical decision-making, but they vary in methodological rigor and quality. The present study was conducted to assess the quality of guidelines available on end-of-life care in patients with cancer using AGREE II. METHODS A comprehensive search was carried out in EMBASE (Excerpta Medica Database), MEDLINE/PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and gray literature sources until December 2016. The quality of the guidelines was assessed independently by five appraisers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). To promote consistency with available studies using AGREE II and identify high-quality guidelines, the AGREE II scores were also categorized as "Strongly recommended," "Recommended with modifications," or "Not recommended." RESULTS A total of 8 guidelines were included in this study. Five of the guidelines were developed based on evidence and two by consensus and one provided no information about its method of development. The highest mean score (82.77%) pertained to "Clarity of presentation" and the lowest to "Editorial independence" (44.80%). Based on the AGREE II results, three guidelines were "Strongly recommended," four were "Recommended with modifications," and one was "Not recommended." CONCLUSION Despite the variations in the quality and strength of the recommendations, a number of guidelines are currently available on end-of-life care. Health team members should be aware of this variability.
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Rhoads S, Amass T. Communication at the End-of-Life in the Intensive Care Unit: A Review of Evidence-Based Best Practices. RHODE ISLAND MEDICAL JOURNAL (2013) 2019; 102:30-33. [PMID: 31795531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article summarizes current data and recommendations regarding the care of patients in an intensive care unit (ICU) at the end of life. Through analysis of recent literature and society guidelines, we identified three areas of focus for practitioners in order to deliver compassionate care to patients and their families at this critical time - family communication, caregiver support, and palliative care involvement. Attention to these topics during critical illness may reduce stress-related disorders in both patients and family members, as well as increase satisfaction with the care delivered.
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Jaime-Pérez JC, Turrubiates-Hernández GA, Nava-Obregón T, Coronado-Hernández B, Gutiérrez-Aguirre H, Cantú-Rodríguez OG, Herrera-Garza JL, Gómez-Almaguer D. Palliative Care for Patients With Hematologic Malignancies in a Low-Middle Income Country: Prevalence of Symptoms and the Need for Improving Quality of Attention at the End of Life. Am J Hosp Palliat Care 2019; 37:600-605. [PMID: 31714147 DOI: 10.1177/1049909119887951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Palliative care (PC) for patients with malignant hematological diseases is scarcely documented, particularly in low- and middle-income countries. This study aimed to document PC provided to patients with hematologic malignancies. METHODS Bidirectional study conducted from July 2016 to June 2019 at the hematology and palliative care departments at a reference center in Northeast Mexico for low-income open population uninsured patients. Clinical records and electronic files of patients with malignant hematological diseases of both sexes and all ages attending an academic hematology center were reviewed. Statistical analysis was performed with the SPSS version 22 program. Acute and chronic leukemias, multiple myeloma, Hodgkin lymphoma, non-Hodgkin lymphoma, and others were included. RESULTS Five-hundred ten patients were studied, of which 148 (29%) died. Eighty-one (15.88%) patients including 31 (20.9%) who died received PC. Median age at palliative diagnosis was 42 (2-91) years. The most common symptom was pain (69.7%). The most frequent reason for palliative referral was treatment-refractory disease (39%). During the last week of life, 19 (95%) of 20 patients had blood sampling; 17 (85%) received antibiotics; 16 (80%) had a urinalysis performed; 16 (80%) received analgesia, including paracetamol (11, 35.5%) and buprenorphine (7, 22.6%); 10 (50%) received blood products; 9 (45%) were intubated; and central venous catheters were inserted in 5 (25%) patients. CONCLUSIONS Palliative care was provided to a minority of patients with hematologic malignancies and considerable improvement is required in its timely use and extension.
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Carter HE, Lee XJ, Gallois C, Winch S, Callaway L, Willmott L, White B, Parker M, Close E, Graves N. Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia. BMJ Open 2019; 9:e030955. [PMID: 31690607 PMCID: PMC6858125 DOI: 10.1136/bmjopen-2019-030955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN Retrospective multicentre cohort study. SETTING Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.
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Teresi JA, Ocepek-Welikson K, Ramirez M, Ornstein KA, Bakken S, Siu A, Luchsinger JA. Psychometric Properties of a Spanish-Language Version of a Short-Form FAMCARE: Applications to Caregivers of Patients With Alzheimer's Disease and Related Dementias. JOURNAL OF FAMILY NURSING 2019; 25:557-589. [PMID: 31423925 PMCID: PMC6891123 DOI: 10.1177/1074840719867345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Although family satisfaction is recognized as a critical indicator of quality care for persons with serious illness, Spanish-language measures are limited. The study aims were to develop a Spanish translation of the short-form Family Satisfaction With End-of-Life Care (FAMCARE), investigate its psychometric properties in Hispanic caregivers to patients with Alzheimer's disease and related dementias (ADRD; N = 317; 209 interviewed in Spanish), and add parameters to an existing item bank. Based on factor analyses, the measure was found to be essentially unidimensional. Reliabilities from a graded item response theory model were high; the average estimate was 0.93 for the total and Spanish-language subsample. Discrimination parameters were high, and the model fit adequate. This is the first study to examine the performance of the short-form FAMCARE measure among Hispanics and caregivers to patients with ADRD. The short-form measure can be recommended for Hispanics and caregivers to patients with ADRD.
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Hockley J, Froggatt K, Van den Block L, Onwuteaka-Philipsen B, Kylänen M, Szczerbińska K, Gambassi G, Pautex S, Payne SA. A framework for cross-cultural development and implementation of complex interventions to improve palliative care in nursing homes: the PACE steps to success programme. BMC Health Serv Res 2019; 19:745. [PMID: 31651314 PMCID: PMC6814133 DOI: 10.1186/s12913-019-4587-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 10/09/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar. METHODS The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support. RESULTS Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1-3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention. CONCLUSIONS There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.
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Richards CA, Hebert PL, Liu CF, Ersek M, Wachterman MW, Taylor LL, Reinke LF, O’Hare AM. Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services. JAMA Netw Open 2019; 2:e1913115. [PMID: 31603487 PMCID: PMC6804019 DOI: 10.1001/jamanetworkopen.2019.13115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022] Open
Abstract
Importance Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care. Objectives To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death. Design, Setting, and Participants This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019. Exposure Cessation of dialysis treatment before death. Main Outcomes and Measures Bereaved Family Survey ratings. Results Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001). Conclusions and Relevance This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
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Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, Taylor LL, O’Hare AM. Family Perceptions of Quality of End-of-Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol 2019; 14:1324-1335. [PMID: 31466952 PMCID: PMC6730503 DOI: 10.2215/cjn.01560219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the quality of end-of-life care for patients with advanced CKD. We describe the relationship between patterns of end-of-life care and dialysis treatment with family-reported quality of end-of-life care in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a retrospective observational study among a national cohort of 9993 veterans with advanced CKD who died in Department of Veterans Affairs facilities between 2009 and 2015. We used logistic regression to evaluate associations between patterns of end-of-life care and receipt of dialysis (no dialysis, acute dialysis, maintenance dialysis) with family-reported quality of end-of-life care. RESULTS Overall, 52% of cohort members spent ≥2 weeks in the hospital in the last 90 days of life, 34% received an intensive procedure, and 47% were admitted to the intensive care unit, in the last 30 days, 31% died in the intensive care unit, 38% received a palliative care consultation in the last 90 days, and 36% were receiving hospice services at the time of death. Most (55%) did not receive dialysis, 12% received acute dialysis, and 34% received maintenance dialysis. Patients treated with acute or maintenance dialysis had more intensive patterns of end-of-life care than those not treated with dialysis. After adjustment for patient and facility characteristics, receipt of maintenance (but not acute) dialysis and more intensive patterns of end-of-life care were associated with lower overall family ratings of end-of-life care, whereas receipt of palliative care and hospice services were associated with higher overall ratings. The association between maintenance dialysis and overall quality of care was attenuated after additional adjustment for end-of-life treatment patterns. CONCLUSIONS Among patients with advanced CKD, care focused on life extension rather than comfort was associated with lower family ratings of end-of-life care regardless of whether patients had received dialysis.
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Gagliardi L, Morassaei S. Optimizing the role of social workers in advance care planning within an academic hospital: an educational intervention program. SOCIAL WORK IN HEALTH CARE 2019; 58:796-806. [PMID: 31347466 DOI: 10.1080/00981389.2019.1645794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/20/2019] [Accepted: 07/16/2019] [Indexed: 06/10/2023]
Abstract
Advance Care Planning (ACP) promotes communication to help patients express future health-care preferences and goals for their medical care. Social workers (SWs) are trained to facilitate complex conversations and assist in various ACP tasks across clinical settings. This three-part mixed-method interventional study implemented a comprehensive education and training program for SWs of a large academic hospital, which used pre- and post-training evaluations, chart review, and qualitative data from debrief sessions to examine ACP skills and confidence, and assess the number of ACP conversations initiated with patients. Self-reported level of preparation to facilitate ACP conversations improved significantly (n = 26; pre 36% versus post 82%; p < .05). A 4-month post-intervention chart audit showed an 8.69 fold increase in the number of initiated ACP conversations. Qualitative analysis identified key themes regarding barriers and enablers of initiating ACP conversations during standard care from the perspective of SWs.
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Tark A, Agarwal M, Dick AW, Stone PW. Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan. J Palliat Med 2019; 22:1032-1038. [PMID: 30789297 PMCID: PMC6735313 DOI: 10.1089/jpm.2018.0626] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.
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Dawood M. End of life care in the emergency department. Emerg Med J 2019; 37:273-278. [PMID: 31409635 DOI: 10.1136/emermed-2019-208632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 11/04/2022]
Abstract
The importance of end of life care (EoLC) for patients and their families is well documented, however, the skills and knowledge of emergency clinicians in delivering EoLC is not widely understood but it is clear from the existing literature that we fall short in delivering consistently good EoLC although there is recognition of the need to improve. This paper will acknowledge the challenges of delivering good EoLC in the emergency department (ED) but more importantly consider practical ways of improving EoLC in the ED in line with best practice guidelines on EoLC.
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Batteux E, Ferguson E, Tunney RJ. On the Likelihood of Surrogates Conforming to the Substituted Judgment Standard When Making End-of-Life Decisions for Their Partner. Med Decis Making 2019; 39:651-660. [PMID: 31354033 PMCID: PMC6794635 DOI: 10.1177/0272989x19862800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/14/2019] [Indexed: 11/16/2022]
Abstract
A considerable proportion of end-of-life decisions are made by the patient's next-of-kin, who can be asked to follow the substituted judgment standard and decide based on the patient's wishes. The question of whether these surrogate decision makers are actually able to do so has become an important issue. In this study, we examined how the likelihood of surrogates conforming to the substituted judgment standard varies with individual differences in mortality acceptance and confidence in their decision making. We recruited 153 participants in romantic relationships between 18 and 80 years old from the general population. We asked them to make hypothetical end-of-life decisions for themselves and on behalf of their partner, as well as predict what their partner would do, and complete a series of questionnaires. Participants predicted that their partner would make similar decisions to their own but were more likely to accept a life-saving treatment that could result in reduced quality of life on their partner's behalf than for themselves. Decisions made by older adults were more likely to conform to the substituted judgment standard, which is encouraging given that they are more likely to be confronted with these decisions in real life, although this was not due to differences in mortality acceptance. Older adults were also more likely to have had previous discussions with their partner and thereby know that person's wishes and feel confident that they made the right decision, but these factors did not affect their likelihood of conforming to the substituted judgment standard. This shows that encouraging discussions about end of life among families would ease the decision process, but more work is needed to ensure that surrogates can adhere to the substituted judgment standard.
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Kerever S, Crozier S, Mino JC, Gisquet E, Resche-Rigon M. Influence of nurse's involvement on practices during end-of-life decisions within stroke units. Clin Neurol Neurosurg 2019; 184:105410. [PMID: 31310921 DOI: 10.1016/j.clineuro.2019.105410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions. PATIENTS AND METHODS This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision. RESULTS Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03). CONCLUSION The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.
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Foley LM. Improving End-of-Life Care for Hospitalized Older Adults: What Can Nurses and Health Care Systems Do? J Gerontol Nurs 2019; 45:2-4. [PMID: 31237657 DOI: 10.3928/00989134-20190612-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fritz L, Zwinkels H, Koekkoek JAF, Reijneveld JC, Vos MJ, Dirven L, Pasman HRW, Taphoorn MJB. Advance care planning in glioblastoma patients: development of a disease-specific ACP program. Support Care Cancer 2019; 28:1315-1324. [PMID: 31243585 PMCID: PMC6989589 DOI: 10.1007/s00520-019-04916-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 06/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unknown if the implementation of an advance care planning (ACP) program is feasible in daily clinical practice for glioblastoma patients. We aimed to develop an ACP program and assess the preferred content, the best time to introduce such a program in the disease trajectory, and possible barriers and facilitators for participation and implementation. METHODS A focus group with health care professionals (HCPs) and individual semi-structured interviews with patients and proxies (of both living and deceased patients) were conducted. RESULTS All predefined topics were considered relevant by participants, including the current situation, worries/fears, (supportive) treatment options, and preferred place of care/death. Although HCPs and proxies of deceased patients indicated that the program should be implemented relatively early in the disease trajectory, patient-proxy dyads were more ambiguous. Several patient-proxy dyads indicated that the program should be initiated later in the disease trajectory. If introduced early, topics about the end of life should be postponed. A frequently mentioned barrier for participation was that the program would be too confronting, while a facilitator was adequate access to information. CONCLUSION This study resulted in an ACP program specifically for glioblastoma patients. Although participants agreed on the program content, the optimal timing of introducing such a program was a matter of debate. Our solution is to offer the program shortly after diagnosis but let patients and proxies decide which topics they want to discuss and when. The impact of the program on several patient- and care-related outcomes will be evaluated in the next step.
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Flint R, Buchanan D, Jamieson S, Cuschieri A, Botros S, Forbes J, George J. The Safer Prescription of Opioids Tool (SPOT): A Novel Clinical Decision Support Digital Health Platform for Opioid Conversion in Palliative and End of Life Care-A Single-Centre Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16111926. [PMID: 31151321 PMCID: PMC6612362 DOI: 10.3390/ijerph16111926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 12/02/2022]
Abstract
Opioid errors are a leading cause of patient harm. Active failures in opioid dose conversion can contribute to error. Conversion is complex and is currently performed manually using tables of approximate equivalence. Apps that offer opioid dose double-checking are available but there are concerns about their accuracy and clinical validation. This study evaluated a novel opioid dose conversion app, The Safer Prescription of Opioids Tool (SPOT), a CE-marked Class I medical device, as a clinician decision support (CDS) platform. This single-centre prospective clinical utility pilot study followed a mixed methods design. Prescribers completed an initial survey exploring their current opioid prescribing practice. Thereafter prescribers used SPOT for opioid dosage conversions in parallel to their usual clinical practice, then evaluated SPOT through a survey and focus group. SPOT matched the Gold Standard result in 258 of 268 (96.3%) calculations. The 10 instances (3.7%) when SPOT did not match were due to a rounding error. Users had a statistically significant increase in confidence in prescribing opioids after using SPOT. Focus group feedback highlighted benefits in Quality Improvement and Safety when using SPOT. SPOT is a safe, reliable and validated CDS that has potential to reduce harms from opioid dosing errors.
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Kerever S, Jacquens A, Smail-Faugeron V, Gayat E, Resche-Rigon M. Methodological management of end-of-life decision data in intensive care studies: A systematic review of 178 randomized control trials published in seven major journals. PLoS One 2019; 14:e0217134. [PMID: 31136601 PMCID: PMC6538318 DOI: 10.1371/journal.pone.0217134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 05/06/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND End-of-life (EOL) decisions are a serious ethical dilemma and are frequently carried out in intensive care units (ICUs). The aim of this systematic review was to investigated the different approaches used in ICUs and reported in randomized controlled trials (RCTs) to address EOL decisions and compare the impact of these different strategies regarding potential bias and mortality estimates. METHODS We identified relevant RCTs published in the past 15 years via PubMed, EMBASE, and CINAHL. In addition, we searched The Cochrane Library and checked registries, including ClinicalTrials.gov to assess concordance between declared and published outcomes. Among the journals we screened were the 3 ICU specialty journals and the four general medicine journals with the highest impact factor. Only RCTs were selected in which in-ICU mortality was the primary or secondary outcome. The primary outcome was information regarding EOL decisions, and the secondary outcome was how EOL decisions were treated in the study analysis. RESULTS A total of 178 relevant trials were identified. The details regarding the methodological aspects resulting from EOL decisions were reported in only 62 articles (35%). The manner in which EOL decisions were considered in the study analysis was very heterogeneous, often leading to a high risk of bias. CONCLUSION There is a heterogeneity regarding the management of data on EOL decisions in randomized control trials with mortality endpoints. Recommendations or rules are required regarding the inclusion of patients with potential EOL decisions in RCT analyses and how to manage such decisions from a methodological point of view. TRIAL REGISTRATION PROSPERO website (CRD42013005724).
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Balboni T, Prigerson HG, Balboni M, Enzinger A, VanderWeele T, Maciejewski PK. A scale to assess religious beliefs in end-of-life medical care. Cancer 2019; 125:1527-1535. [PMID: 30825390 PMCID: PMC6525567 DOI: 10.1002/cncr.31946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/19/2018] [Accepted: 04/24/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Studies postulate that certain religious beliefs related to medical care influence the end-of-life (EOL) medical decision making and care of patients with advanced cancer. Because to the best of the authors' knowledge no current measure explicitly assesses such beliefs, in the current study the authors introduced and evaluated the Religious Beliefs in EOL Medical Care (RBEC) scale, a new measure designed to assess religious beliefs within the context of EOL cancer care. METHODS The RBEC scale consists of 7 items designed to reflect religious beliefs in EOL medical care. Its psychometric properties were evaluated in a sample of 275 patients with advanced cancer from the Coping With Cancer II study, a National Cancer Institute-funded, multisite, longitudinal, observational study of communication processes and outcomes in EOL cancer care. RESULTS The RBEC scale proved to be internally consistent (Cronbach α, .81), unidimensional, positively associated with other indicators of patients' religiousness and spirituality (establishing its convergent validity), and inversely associated with patients' terminal illness understanding and acceptance (establishing its criterion validity), suggesting its potential clinical usefulness in promoting informed EOL decision making. The majority of patients (87%) reported some ("somewhat," "quite a bit," or "a great deal") endorsement of at least 1 RBEC item and a majority (62%) endorsed ≥3 RBEC items. CONCLUSIONS The RBEC scale is a reliable and valid tool with which to assess religious beliefs within the context of EOL medical care, beliefs that frequently are endorsed and inversely associated with terminal illness understanding.
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Egelund EF, Gannon J, Motycka C, Smith WT, Kraemer DF, Solomon KH. A Simulated Approach to Fostering Competency in End-of-Life Care Among Pharmacy Students. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2019; 83:6904. [PMID: 31223159 PMCID: PMC6581347 DOI: 10.5688/ajpe6904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 07/06/2018] [Indexed: 05/05/2023]
Abstract
Objective. To determine if pharmacy students participating in simulation-based scenarios reported fewer learning needs about the transition from acute to end-of-life (EOL) care compared to students participating in solely case-based scenario delivery. Methods. Four end-of-life cases were developed for both paper-based case study and simulation delivery. Pharmacy students on three distant campuses were exposed to the case study approach while four teams of nine to ten pharmacy students were exposed to simulated versions of the same cases. A validated questionnaire was administered before and after exposure to assess end-of-life care learning needs. Results were analyzed following a Bonferroni-adjustment for multiple testing. Results. The case study groups produced similar pre/post changes on the questionnaire. After results were pooled and compared to the simulation only group, significantly higher changes in pre/post scores were found for the simulation group. Conclusion. Pharmacy students exposed to simulated EOL scenarios experienced significantly reduced learning needs following the scenarios, unlike their classroom-based counterparts.
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Abstract
Palliative care (PC) teams are primed to support patients with advanced illness, including patients with mechanical circulatory support (MCS), and are increasingly being called upon to help care for these patients. Detailed guidelines for PC engagement are lacking despite key stakeholders' endorsements of collaboration. PC should encompass the decision-making period, the duration of therapy, and end-of-life care. PC teams can assist with symptom management, advance care planning, and communication across the continuum of MCS care. However, the current state of MCS and PC collaboration is variable and can be hindered by staffing challenges and clinician discomfort. To best care for patients who receive advanced cardiopulmonary life-sustaining therapies, meaningful engagement of PC during all phases of MCS is essential.
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Alminoja A, Piili RP, Hinkka H, Metsänoja R, Hirvonen O, Tyynelä-Korhonen K, Kaleva-Kerola J, Saarto T, Kellokumpu-Lehtinen PLI, Lehto JT. Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians? In Vivo 2019; 33:903-909. [PMID: 31028215 PMCID: PMC6559926 DOI: 10.21873/invivo.11557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care. MATERIALS AND METHODS A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016. RESULTS Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs. CONCLUSION Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.
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