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Fokin AA, Wycech J, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study. Am J Hosp Palliat Care 2020; 37:1068-1075. [PMID: 32319314 DOI: 10.1177/1049909120919672] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. METHODS Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019. Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). RESULTS Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC (P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). CONCLUSIONS Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA
| | | | - Susan Koff
- 535241TrustBridge Health, West Palm Beach, FL, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA.,Department of Surgery, Herbert Wertheim College of Medicine, 306688Florida International University, Miami, FL, USA
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Armitage-Chan E. Best Practice in Supporting Professional Identity Formation: Use of a Professional Reasoning Framework. JOURNAL OF VETERINARY MEDICAL EDUCATION 2020; 47:125-136. [PMID: 31194617 DOI: 10.3138/jvme.0218-019r] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Professional identity and professionalism education are increasingly important to veterinary education, but many of the concepts remain intangible to veterinary students, and engagement is a persistent challenge. While whole-curriculum integration is recommended for a successful professional studies program, this is complicated by clinical faculty's discomfort with the content. Where professional studies education is centered around professional identity formation, a key element of this is the multi-perspective nature of veterinary work, with the veterinarian negotiating the needs of multiple stakeholders in animal care. Constructing teaching around a framework of professional reasoning, which incorporates the negotiation of different stakeholder needs, ethical decision making, communication, teamwork, and outcome monitoring, offers the potential to make professional identity a concept more visible to students in veterinary work, and guides students in the contextualization of taught material. A framework is presented for veterinary professional reasoning that signposts wider curriculum content and helps illustrate where material such as veterinary business studies, animal welfare, the human-animal bond, and professional responsibility, as well as attributes such as empathy and compassion, all integrate in the decisions and actions of the veterinary professional. The aims of this framework are to support students' engagement in professional studies teaching and help them use workplace learning experiences to construct an appropriate professional identity for competence and resilience in the clinic. For faculty involved in curriculum design and clinical teaching, the framework provides a tool to support the integration of professional identity concepts across the extended curriculum.
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Pereira J, Chary S, Moat JB, Faulkner J, Gravelle-Ray N, Carreira O, Vincze D, Parsons G, Riordan B, Hayawi L, Tsang TWY, Ndoria L. Pallium Canada's Curriculum Development Model: A Framework to Support Large-Scale Courseware Development and Deployment. J Palliat Med 2020; 23:759-766. [PMID: 32155359 PMCID: PMC7249472 DOI: 10.1089/jpm.2019.0292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The need to improve access to palliative care across multiple settings and disease groups has been identified. This requires equipping health care professionals from many different professions, including physicians and nurses, among others, with basic palliative care competencies to provide a palliative care approach. Pallium Canada's Curriculum Development Framework supports the development, deployment, and dissemination, on a large scale, of multiple courses targeting health care professionals across multiple settings of care and disease groups. The Framework is made up of eight phases: (1) Concept, (2) Decision, (3) Curriculum Planning, (4) Prototype Development, (5) Piloting, (6) Dissemination, (7) Language and Cultural Adaptation, and (8) Ongoing Maintenance and Updates. Several of these phases include iterative cyclical activities. The framework allows multiple courses to be developed simultaneously, staggered in a production line with each phase and their corresponding activities requiring different levels of resources and stakeholder engagement. The framework has allowed Pallium Canada to develop, launch, and maintain numerous versions of its Learning Essential Approaches to Palliative Care (LEAP) courses concurrently. It leverages existing LEAP courses and curriculum materials to produce new LEAP courses, allowing significant efficiencies and maximizing output. This article describes the framework and its various activities, which we believe could be very useful for other jurisdictions undertaking the work of developing education programs to spread the palliative care approach across multiple settings, specialties, and disease groups.
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Affiliation(s)
- José Pereira
- Pallium Canada, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada; University of Navarra, Navarra, Spain
| | - Srini Chary
- Pallium Canada, Ottawa, Ontario, Canada.,Palliative Care Services, Alberta Health Services, Calgary Zone, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | | | - Tammy W Y Tsang
- Pallium Canada, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
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Lee KC, Udelsman BV, Streid J, Chang DC, Salim A, Livingston DH, Lindvall C, Cooper Z. Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma. J Pain Symptom Manage 2020; 59:225-232.e2. [PMID: 31562891 DOI: 10.1016/j.jpainsymman.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive. OBJECTIVES To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review. METHODS Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery. RESULTS There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay. CONCLUSION NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David H Livingston
- Division of Trauma and Surgical Critical Care, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Palliative care referral in ST-segment elevation myocardial infarction complicated with cardiogenic shock in the United States. Heart Lung 2020; 49:25-29. [DOI: 10.1016/j.hrtlng.2019.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/13/2019] [Accepted: 10/16/2019] [Indexed: 01/11/2023]
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Palliative Care Use in Patients With Acute Myocardial Infarction. J Am Coll Cardiol 2020; 75:113-117. [DOI: 10.1016/j.jacc.2019.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/09/2019] [Accepted: 11/05/2019] [Indexed: 12/22/2022]
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Ribeiro AF, Martins Pereira S, Gomes B, Nunes R. Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis. Palliat Med 2019; 33:1241-1254. [PMID: 31296110 DOI: 10.1177/0269216319862160] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care. AIM To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration. DESIGN A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676). DATA SOURCES Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal. RESULTS A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units. CONCLUSION This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.
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Affiliation(s)
| | - Sandra Martins Pereira
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,Centro de Estudos em Gestão e Economia (CEGE), Porto Católica Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Barbara Gomes
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal.,Cicely Saunders Institute, King's College London, London, UK
| | - Rui Nunes
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,International Network UNESCO Chair in Bioethics
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Defining the surgical critical care research agenda: Results of a gaps analysis from the Critical Care Committee of the American Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 88:320-329. [DOI: 10.1097/ta.0000000000002532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Lee KC, Walling AM, Senglaub SS, Kelley AS, Cooper Z. Defining Serious Illness Among Adult Surgical Patients. J Pain Symptom Manage 2019; 58:844-850.e2. [PMID: 31404642 PMCID: PMC7155422 DOI: 10.1016/j.jpainsymman.2019.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context. OBJECTIVES The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts. METHODS We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement. RESULTS All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V. CONCLUSION We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Affiliated Adjunct Staff, RAND Health, Los Angeles, California, USA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Hebrew SeniorLife Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Shoultz TH, Moore M, Reed MJ, Kaplan SJ, Bentov I, Hough C, Taitsman LA, Mitchell SH, So GE, Arbabi S, Phelan H, Pham T. Trauma Providers' Perceptions of Frailty Assessment: A Mixed-Methods Analysis of Knowledge, Attitudes, and Beliefs. South Med J 2019; 112:159-163. [PMID: 30830229 DOI: 10.14423/smj.0000000000000948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. METHODS We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. RESULTS One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. CONCLUSIONS Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.
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Affiliation(s)
- Thomas H Shoultz
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Megan Moore
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - May J Reed
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Stephen J Kaplan
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Itay Bentov
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Catherine Hough
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Lisa A Taitsman
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Steven H Mitchell
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Grace E So
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Saman Arbabi
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Herb Phelan
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
| | - Tam Pham
- From the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, the School of Social Work, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, the Department of Surgery, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington, the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, the Department of Orthopedics and Sports Medicine, University of Washington, Seattle, the Department of Emergency Medicine, University of Washington, Seattle, the Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, the Department of Surgery, Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, and the Department of Surgery, Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington
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Mittel A, Hua M. Supporting the Geriatric Critical Care Patient: Decision Making, Understanding Outcomes, and the Role of Palliative Care. Anesthesiol Clin 2019; 37:537-546. [PMID: 31337483 PMCID: PMC6719536 DOI: 10.1016/j.anclin.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Geriatric admissions to the intensive care unit (ICU) are common and require unique considerations for ICU clinicians. Admission to the ICU should be considered on an individual-patient basis. It is reasonable to consider a "trial of critical care" for many patients, even those who have uncertain chances of meaningful recovery. Quality of life and functional independence are especially important to older adults, and these outcomes should be considered when weighing the risks and benefits of admission or continuing ICU care.
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Affiliation(s)
- Aaron Mittel
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH505-C, New York, NY 10032, USA.
| | - May Hua
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, PH5, Room 527D, New York, NY 10032, USA
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62
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Affiliation(s)
- Pringl Miller
- Rush University Medical Center, Kellogg Building-Suite 1126, 1717 West Congress Parkway, Chicago, IL 60612, USA.
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Kyeremanteng K, Beckerleg W, Wan C, Vanderspank-Wright B, D'Egidio G, Sutherland S, Hartwick M, Gratton V, Sarti AJ. Survey on Barriers to Critical Care and Palliative Care Integration. Am J Hosp Palliat Care 2019; 37:108-116. [PMID: 31416329 DOI: 10.1177/1049909119867658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration. MATERIALS AND METHODS A self-administered questionnaire was developed by a multidisciplinary team. Survey items were extracted from published quality indicators in EOLC and barriers to ICU-PC integration. The study took place at 2 academic institutions. Participants consisted of physicians and nurses, ICU administrators, and allied health workers. RESULTS An overall response of 45% was achieved. Of total, 85% of the respondents were ICU nurses. The following main themes were identified: (1) There is a poor presence of PC in the ICU and 78% of respondents felt that increasing ICU-PC integration will improve quality of EOLC; (2) the main barrier to integration was unrealistic patient and/or family expectations; and (3) criteria-triggered consultation to PC was the most feasible way to achieve integration. CONCLUSION Our findings indicate that the majority of respondents perceive that the presence of PC in ICU will improve EOLC. Future quality improvement initiatives can focus on developing a set of criteria for triggering PC consults.
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Affiliation(s)
- Kwadwo Kyeremanteng
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.,Institut du Savoir Montfort, Ottawa, Ontario, Canada.,The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
| | | | - Cynthia Wan
- Faculty of Social Sciences, School of Psychology, University of Ottawa, Ontario, Canada
| | | | - Gianni D'Egidio
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada.,Division of Critical Care Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | | | - Aimee J Sarti
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
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65
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services. Am J Hosp Palliat Care 2019; 37:250-257. [PMID: 31387366 DOI: 10.1177/1049909119867904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.
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Affiliation(s)
| | - Timothy Feeney
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Chanmin Kim
- Boston University School of Public Health, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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Moynihan KM, Snaman JM, Kaye EC, Morrison WE, DeWitt AG, Sacks LD, Thompson JL, Hwang JM, Bailey V, Lafond DA, Wolfe J, Blume ED. Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model. Pediatrics 2019; 144:peds.2019-0160. [PMID: 31366685 PMCID: PMC6855829 DOI: 10.1542/peds.2019-0160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/04/2023] Open
Abstract
Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.
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Affiliation(s)
- Katie M. Moynihan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wynne E. Morrison
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Aaron G. DeWitt
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Loren D. Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jess L. Thompson
- Department of Cardiothoracic Surgery, Children’s Heart Center, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Jennifer M. Hwang
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Pediatrics, Perelman School of Medicine, The University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Valerie Bailey
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts
| | - Deborah A. Lafond
- PANDA Palliative Care Team, Children’s National and School of Medicine, The George Washington University, Washington, District of Columbia
| | - Joanne Wolfe
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth D. Blume
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
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67
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Fernando GVMC, Prathapan S. What do young doctors know of palliative care; how do they expect the concept to work? : A 'palliative care' knowledge and opinion survey among young doctors. BMC Res Notes 2019; 12:419. [PMID: 31311576 PMCID: PMC6636058 DOI: 10.1186/s13104-019-4462-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/09/2019] [Indexed: 01/12/2023] Open
Abstract
Objectives Discipline of palliative care is still evolving in developed parts of the world while it remains at an infantile stage in Sri Lanka which has not been formally assessed as of today. We aimed at evaluating the level of palliative care knowledge and opinions among young medical graduates. A descriptive cross-sectional study was carried out among pre-residency medical graduates of Sri Lanka through a social media based online survey. The pre-tested questionnaire assessed the level of knowledge on general principles, service organization, clinical management and ethical considerations while it also evaluated their opinions. Results Response rate was 35.8% (n = 351). The average score among the respondents was 37.25% [standard deviation (SD) = 11.975]. Specific knowledge on “general principles” was adequate (score ≥ 50%) with an average of 62.61%, SD = 24.5 while “ethics” was observed to be the area with the poorest knowledge (average score = 19.55%, SD = 22). Average scores for “service organization” and “managerial aspects” were 34.54%, SD = 17.6 and 32.26%, SD = 22.3, respectively. The majority (> 90%) believed that de-novo establishment of hospice, hospital and community-based palliative services would sustainably improve holistic patient care. Measures must be taken to optimize basic palliative care knowledge among the undergraduates in view of achieving Universal Health Coverage in the long term. Electronic supplementary material The online version of this article (10.1186/s13104-019-4462-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G V M C Fernando
- National Centre for Primary Care and Allergy Research, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka. .,Department of Family Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka.
| | - S Prathapan
- Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
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Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions. Injury 2019; 50:1064-1067. [PMID: 30745124 DOI: 10.1016/j.injury.2019.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources. METHODS Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05. RESULTS We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC. CONCLUSION WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.
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Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee. J Trauma Acute Care Surg 2019; 86:737-743. [DOI: 10.1097/ta.0000000000002155] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Butler CR, Schwarze ML, Katz R, Hailpern SM, Kreuter W, Hall YN, Montez Rath ME, O'Hare AM. Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD. J Am Soc Nephrol 2019; 30:481-491. [PMID: 30782596 PMCID: PMC6405144 DOI: 10.1681/asn.2018101002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. METHODS We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. RESULTS Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. CONCLUSIONS Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, University of Wisconsin, Madison, Wisconsin
| | - Ronit Katz
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Susan M Hailpern
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - William Kreuter
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Yoshio N Hall
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Maria E Montez Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Medicine, Stanford University, Stanford, California; and
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington
- Division of Nephrology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
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Ando T, Adegbala O, Uemura T, Akintoye E, Ashraf S, Briasoulis A, Takagi H, Afonso L. Incidence, Trends, and Predictors of Palliative Care Consultation After Aortic Valve Replacement in the United States. J Palliat Care 2018; 34:111-117. [DOI: 10.1177/0825859718819433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Aim: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database. Materials and Methods: We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients. Results: A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 ( P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR ( P = .86). Age 80 to 89 (aOR: 1.93), age ≥90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR. Conclusions: There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.
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Affiliation(s)
- Tomo Ando
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Oluwole Adegbala
- Department of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University–Hackensack Meridian School of Medicine, Englewood, NJ, USA
| | - Takeshi Uemura
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, NY, USA
| | - Emmanuel Akintoye
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Said Ashraf
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Alexandros Briasoulis
- Divison of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Luis Afonso
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
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Lilley EJ, Lee KC, Scott JW, Krumrei NJ, Haider AH, Salim A, Gupta R, Cooper Z. The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge. J Trauma Acute Care Surg 2018; 85:992-998. [PMID: 29851910 PMCID: PMC6202158 DOI: 10.1097/ta.0000000000002000] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Affiliation(s)
- Elizabeth J Lilley
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts (E.J.L., K.C.L., J.W.S., A.H.H., A.S., Z.C.); Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (E.J.L., N.J.K., R.G.); Department of Surgery, University of California San Diego, La Jolla, California (K.C.L.); and Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., Z.C.)
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National Trends (2009–2013) for Palliative Care Utilization for Patients Receiving Prolonged Mechanical Ventilation*. Crit Care Med 2018; 46:1230-1237. [DOI: 10.1097/ccm.0000000000003182] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Altaker KW, Howie-Esquivel J, Cataldo JK. Relationships Among Palliative Care, Ethical Climate, Empowerment, and Moral Distress in Intensive Care Unit Nurses. Am J Crit Care 2018; 27:295-302. [PMID: 29961665 DOI: 10.4037/ajcc2018252] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care unit nurses experience moral distress when they feel unable to deliver ethically appropriate care to patients. Moral distress is associated with nurse burnout and patient care avoidance. OBJECTIVES To evaluate relationships among moral distress, empowerment, ethical climate, and access to palliative care in the intensive care unit. METHODS Intensive care unit nurses in a national database were recruited to complete an online survey based on the Moral Distress Scale-Revised, Psychological Empowerment Index, Hospital Ethical Climate Survey, and a palliative care delivery questionnaire. Descriptive, correlational, and regression analyses were performed. RESULTS Of 288 initiated surveys, 238 were completed. Participants were nationally representative of nurses by age, years of experience, and geographical region. Most were white and female and had a bachelor's degree. The mean moral distress score was moderately high, and correlations were found with empowerment (r = -0.145; P = .02) and ethical climate scores (r = -0.354; P < .001). Relationships between moral distress and empowerment scores and between moral distress and ethical climate scores were not affected by access to palliative care. Nurses reporting palliative care access had higher moral distress scores than those without such access. Education, ethnicity, unit size, access to full palliative care team, and ethical climate explained variance in moral distress scores. CONCLUSIONS Poor ethical climate, unintegrated palliative care teams, and nurse empowerment are associated with increased moral distress. The findings highlight the need to promote palliative care education and palliative care teams that are well integrated into intensive care units.
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Affiliation(s)
- Krista Wolcott Altaker
- Krista Wolcott Altaker is an assistant professor of nursing at Sonoma State University, Rohnert Park, California. Jill Howie-Esquivel is an associate professor of nursing at the University of Virginia, Charlottesville, Virginia. Janine K. Cataldo is a professor and chair of the Department of Physiological Nursing at the University of California, San Francisco
| | - Jill Howie-Esquivel
- Krista Wolcott Altaker is an assistant professor of nursing at Sonoma State University, Rohnert Park, California. Jill Howie-Esquivel is an associate professor of nursing at the University of Virginia, Charlottesville, Virginia. Janine K. Cataldo is a professor and chair of the Department of Physiological Nursing at the University of California, San Francisco
| | - Janine K. Cataldo
- Krista Wolcott Altaker is an assistant professor of nursing at Sonoma State University, Rohnert Park, California. Jill Howie-Esquivel is an associate professor of nursing at the University of Virginia, Charlottesville, Virginia. Janine K. Cataldo is a professor and chair of the Department of Physiological Nursing at the University of California, San Francisco
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Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study. Intensive Crit Care Nurs 2018; 48:75-84. [PMID: 29937078 DOI: 10.1016/j.iccn.2018.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility. RESEARCH DESIGN A mixed-methods study design was used. SETTING AND SAMPLE The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire. MAIN OUTCOME MEASURES The main outcomes were the acceptability and feasibility of the educational intervention. FINDINGS The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions. CONCLUSION Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.
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Abstract
PURPOSE OF REVIEW The benefits of palliative care for critically ill patients are well recognized, yet acceptance into surgical culture is lagging. With the increasing proportion of geriatric trauma patients, integration of palliative medicine within daily intensive care services to facilitate goal-concordant care is imperative. RECENT FINDINGS Misconceptions of palliative medicine as it applies to trauma patients linger among trauma surgeons and many continue to practice without routine consultation of a palliative care service. Aggressive end-of-life care does not correlate with an improved family perception of medical care received near death. Additionally, elderly patients near the end of life often prefer palliative treatments over life-extending therapy, and their treatment preferences are often not achieved. A new geriatric-specific prognosis calculator estimates the risk of mortality after trauma, which is useful in starting goals of care discussions with older patients and their families. SUMMARY Shifting our quality focus from 30-day mortality rates to measurements of symptom control and achievement of patient treatment preferences will prioritize patient beneficence and autonomy. Ownership of surgical palliative care as a service provided by acute care surgeons will ensure that our patients with incurable injury and illness will receive optimal patient-centered care.
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Klinedinst R, Kornfield ZN, Hadler RA. Palliative Care for Patients With Advanced Heart Disease. J Cardiothorac Vasc Anesth 2018; 33:833-843. [PMID: 29793760 DOI: 10.1053/j.jvca.2018.04.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Indexed: 11/11/2022]
Abstract
Over the past 2 decades, the discipline of palliative care has evolved and expanded such that it is now the standard of care for a variety of acute and chronic processes. Although there are recommendations encouraging incorporation of palliative care into the routine management of patients with chronic cardiac processes, such as congestive heart failure, implementation has been challenging, and nowhere more so than in the cardiac surgical population. However, as the boundaries of surgical care have expanded to include progressively more complex cases, increasing attention has been given to the integration of palliative care into their management. In this review article, the authors describe the existing evidence for palliative care team involvement in patients with non-operative and surgical cardiac diseases and examine future directions for growth in this field.
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Affiliation(s)
- Rachel Klinedinst
- Division of Palliative Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Z Noah Kornfield
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel A Hadler
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Henderson CM, Wilfond BS, Boss RD. Bringing Social Context Into the Conversation About Pediatric Long-term Ventilation. Hosp Pediatr 2018; 8:hpeds.2016-0168. [PMID: 29326228 DOI: 10.1542/hpeds.2016-0168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Carrie M Henderson
- Division of Pediatric Critical Care Medicine and Center for Bioethics and Medical Humanities, University of Mississippi Medical Center, Jackson, Mississippi
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute and Division of Bioethics, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Renee D Boss
- Division of Neonatology, Department of Pediatrics, and Berman Institute of Bioethics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Lilley EJ, Scott JW, Weissman JS, Krasnova A, Salim A, Haider AH, Cooper Z. End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals. JAMA Surg 2018; 153:44-50. [PMID: 28975244 PMCID: PMC5833626 DOI: 10.1001/jamasurg.2017.3148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/21/2017] [Indexed: 01/19/2023]
Abstract
Importance More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.
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Affiliation(s)
- Elizabeth J. Lilley
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - John W. Scott
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Anna Krasnova
- The Center for Surgery and Public Health, Boston, Massachusetts
| | - Ali Salim
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Adil H. Haider
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Deputy Editor, JAMA Surgery
| | - Zara Cooper
- The Center for Surgery and Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Hahne P, Lundström S, Leveälahti H, Winnhed J, Öhlén J. Changes in professionals' beliefs following a palliative care implementation programme at a surgical department: a qualitative evaluation. BMC Palliat Care 2017; 16:77. [PMID: 29282050 PMCID: PMC5745985 DOI: 10.1186/s12904-017-0262-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One ambition regarding palliative care is that it should be more accessible to patients and families regardless of care setting. Previous studies show many difficulties and shortcomings in the care of patients with palliative care needs in acute care facilities, but also challenges regarding efforts to implement palliative care. The aim of this study is to evaluate how the implementation of palliative care, using a combination of integration and consultation strategies, can change beliefs regarding palliative care among professionals in a surgical department. METHOD In order to explore professionals' experiential outcome of an educational implementation strategy, a before-after qualitative design was used. The study was based on three focus group discussions. Two discussions were conducted before introducing the implementation strategy and one was conducted after. The participants consisted of five nurses and two specialist surgeons from a surgical department in Sweden. The focus group discussions revealed a variety of different attitudes and beliefs, which were analysed using qualitative systematic text condensation. RESULTS Beliefs regarding palliative care were identified in seven areas; the importance of palliative care, working methods in palliative care, team collaboration in palliative care, collegial support, discussions about diagnosis, symptoms at the end of life, and families of patients in palliative care. Changes in beliefs were seen in all areas except one: team collaboration in palliative care. CONCLUSION It is possible to change the beliefs of health care professionals in a surgical department regarding palliative care through the implementation of palliative knowledge. Beliefs were changed from an individual to a collective development where the group initiated a shared palliative working method. The changes observed were palliative care being described as more complex and participants differentiating between surgical care and palliative care.
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Affiliation(s)
- Pia Hahne
- Stockholms Sjukhem Foundation, Mariebergsgatan 22, 112 35 Stockholm, Sweden
- Ersta Sköndal Bräcke University College, Box 111 89, -100 61 Stockholm, SE Sweden
| | - Staffan Lundström
- Stockholms Sjukhem Foundation, Mariebergsgatan 22, 112 35 Stockholm, Sweden
- Department of Oncology-Pathology Karolinska Institutet, Stockholm, Sweden
| | - Helena Leveälahti
- Stockholms Sjukhem Foundation, Mariebergsgatan 22, 112 35 Stockholm, Sweden
| | - Janet Winnhed
- Stockholms Sjukhem Foundation, Mariebergsgatan 22, 112 35 Stockholm, Sweden
- ASIH Praktikertjänst Västerort N.Ä.R.A, Vällingby, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences and University of Gothenburg Center for Person-Centered Care, Salgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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81
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Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey. Support Care Cancer 2017; 26:1773-1780. [DOI: 10.1007/s00520-017-4014-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/05/2017] [Indexed: 01/08/2023]
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Impact of Public Reporting of 30-day Mortality on Timing of Death after Coronary Artery Bypass Graft Surgery. Anesthesiology 2017; 127:953-960. [PMID: 28906266 DOI: 10.1097/aln.0000000000001884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent reports have raised concerns that public reporting of 30-day mortality after cardiac surgery may delay decisions to withdraw life-sustaining therapies for some patients. The authors sought to examine whether timing of mortality after coronary artery bypass graft surgery significantly increases after day 30 in Massachusetts, a state that reports 30-day mortality. The authors used New York as a comparator state, which reports combined 30-day and all in-hospital mortality, irrespective of time since surgery. METHODS The authors conducted a retrospective cohort study of patients who underwent coronary artery bypass graft surgery in hospitals in Massachusetts and New York between 2008 and 2013. The authors calculated the empiric daily hazard of in-hospital death without censoring on hospital discharge, and they used joinpoint regression to identify significant changes in the daily hazard over time. RESULTS In Massachusetts and New York, 24,864 and 63,323 patients underwent coronary artery bypass graft surgery, respectively. In-hospital mortality was low, with 524 deaths (2.1%) in Massachusetts and 1,398 (2.2%) in New York. Joinpoint regression did not identify a change in the daily hazard of in-hospital death at day 30 or 31 in either state; significant joinpoints were identified on day 10 (95% CI, 7 to 15) for Massachusetts and days 2 (95% CI, 2 to 3) and 12 (95% CI, 8 to 15) for New York. CONCLUSIONS In Massachusetts, a state with a long history of publicly reporting cardiac surgery outcomes at day 30, the authors found no evidence of increased mortality occurring immediately after day 30 for patients who underwent coronary artery bypass graft surgery. These findings suggest that delays in withdrawal of life-sustaining therapy do not routinely occur as an unintended consequence of this type of public reporting.
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83
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Schuster M, Ferner M, Bodenstein M, Laufenberg-Feldmann R. [Palliative therapy concepts in intensive care medicine]. Anaesthesist 2017; 66:233-239. [PMID: 28378133 DOI: 10.1007/s00101-017-0294-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Involvement of palliative care is so far not common practice for critically ill patients on surgical intensive care units (ICUs) in Germany. The objectives of palliative care concepts are improvement of patient quality of life by relief of disease-related symptoms using an interdisciplinary approach and support of patients and their relatives considering their current physical, psychological, social and spiritual needs. The need for palliative care can be identified via defined screening criteria. Integration of palliative care can either be realized using a consultative model which focusses on involvement of palliative care consultants or an integrative model which embeds palliative care principles into the routine daily practice by the ICU team. Early integration of palliative care in terms of advance care planning (ACP) can lead to an increase in goals of care discussions and quality of life as well as a decrease of mortality and length of stay on the ICU. Moreover, stress reactions of relatives and ICU staff can be reduced and higher satisfaction with therapy can be achieved. The core of goal of care discussions is professional and well-structured communication between patients, relatives and staff. Consideration of palliative care principles by model-based integration into ICU practice can improve complex intensive care courses of disease in a productive but dignified way without neglecting curative attempts.
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Affiliation(s)
- M Schuster
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - M Ferner
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - M Bodenstein
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
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84
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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85
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Mun E, Nakatsuka C, Umbarger L, Ruta R, Mccarty T, Machado C, Ceria-Ulep C. Use of Improving Palliative Care in the ICU (Intensive Care Unit) Guidelines for a Palliative Care Initiative in an ICU. Perm J 2017; 21:16-037. [PMID: 28241905 DOI: 10.7812/tpp/16-037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE For improved utilization of the existing palliative care team in the intensive care unit (ICU), a process was needed to identify patients who might need a palliative care consultation in a timelier manner. METHODS A systematic method to create a new program that would be compatible with our specific ICU environment and patient population was developed. A literature review revealed a fairly extensive array of reports and numerous clinical practice guidelines, which were assessed for information and strategies that would be appropriate for our unit. RESULTS The recommendations provided by the Center to Advance Palliative Care from its Improving Palliative Care in the ICU project were used to successfully implement a new palliative care initiative in our ICU. CONCLUSION The guidelines provided by the Improving Palliative Care in the ICU project were an important tool to direct the development of a new palliative care ICU initiative.
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Affiliation(s)
- Eluned Mun
- Retired Intensive Care Nurse and a current Nurse Practitioner at the Rehabilitation Hospital of the Pacific in Honolulu, HI.
| | - Craig Nakatsuka
- Retired Palliative Care and Internal Medicine Physician at Kaiser Permanente Medical Center at Moanalua in Honolulu, HI.
| | - Lillian Umbarger
- Intensivist and Pulmonologist at Kaiser Permanente Medical Center at Moanalua in Honolulu, HI.
| | - Ruth Ruta
- Intensive Care Nurse at Kaiser Permanente Medical Center at Moanalua in Honolulu, HI.
| | - Tracy Mccarty
- Clinical Coordinator for the Intensive Care Unit at Kaiser Permanente Medical Center at Moanalua in Honolulu, HI.
| | - Cynthia Machado
- Intensive Care Nurse at Kaiser Permenente Medical Center at Moanalua in Honolulu, HI.
| | - Clementina Ceria-Ulep
- Professor and Department Chair in the School of Nursing and Dental Hygiene at the University of Hawaii at Manoa in Honolulu.
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86
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Freeman RK, Arevalo G, Ascioti AJ, Dake M, Mahidhara RS. An Assessment of the Frequency of Palliative Procedures in Thoracic Surgery. JOURNAL OF SURGICAL EDUCATION 2017; 74:878-882. [PMID: 28347662 DOI: 10.1016/j.jsurg.2017.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/01/2017] [Accepted: 02/21/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum. METHODS A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality, and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures. RESULTS During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural or pericardial effusion or both, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula, and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment before thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy. CONCLUSIONS This investigation found that thoracic surgeons commonly care for patients when the intention or indication or both is palliation. Most of these patients have an associated malignancy, a poor performance status and a projected significantly decreased survival compared with the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana.
| | - Gabriel Arevalo
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Anthony J Ascioti
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Megan Dake
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Raja S Mahidhara
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
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McGreevy CM, Bryczkowski S, Pentakota SR, Berlin A, Lamba S, Mosenthal AC. Unmet palliative care needs in elderly trauma patients: can the Palliative Performance Scale help close the gap? Am J Surg 2017; 213:778-784. [DOI: 10.1016/j.amjsurg.2016.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/19/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
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Curtis E, Thomas D, Cocanour CS. Palliative Care in the Elderly Injured Patient. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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89
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Abstract
This article explores the 2014 Institute of Medicine׳s recommendation concerning primary palliative care as integral to all neonates and their families in the intensive care setting. We review trends in neonatology and barriers to implementing palliative care in intensive care settings. Neonatal primary palliative care education should address the unique needs of neonates and their families. The neonatal intensive care unit needs a mixed model of palliative care, where the neonatal team provides primary palliative care and the palliative subspecialist consults for more complex or refractory situations that exceed the primary team׳s skills or available time.
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Affiliation(s)
- Krishelle L Marc-Aurele
- Department of Pediatrics, UC San Diego Medical Center, University of California, 402 Dickinson St MPF 1-140, San Diego, CA 92013.
| | - Nancy K English
- College of Nursing, University of Colorado Health Sciences, Aurora, CO
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Lenz K, Hofmann-Bichler B, Pihringer J, Firlinger F, Pickl A, Clodi M. [Palliative care consultation in the ICU : Descriptive analysis of internal medicine intensive care using a mixed model over 12 months]. Med Klin Intensivmed Notfmed 2017; 112:724-730. [PMID: 28150164 DOI: 10.1007/s00063-017-0261-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/29/2016] [Accepted: 01/08/2017] [Indexed: 11/25/2022]
Abstract
We retrospectively analyzed the data of 56 of 669 critically ill patients admitted to an internal medicine intensive care unit (ICU) with palliative care provided by a palliative care team over the period of 12 months. For delivering palliative care, we used a mixed model-consisting of both integrative and consultative elements. SAPS III severity score in patients with palliative care was 63 ± 15 compared to 50 ± 15 in all critically ill patients. Hospital mortality was 62.5 vs. 16%. After 3 months, 19.6% of patients with palliative care provided by the palliative care team were still alive. In 15 patients curative therapies were discontinued, while there was no further escalation of the therapy in 30 patients. In 47 patients, special help to the relatives was offered. In 13 cases, there was a disagreement between relatives and the ICU team; in 5 cases a family conference was implemented. Two patients wanted extensive intensive care therapy, despite unfavorable prognosis; one patient wished to die. One patient had an advanced directive.
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Affiliation(s)
- K Lenz
- Abteilung für Innere Medizin und Intensivmedizin, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich.
| | - B Hofmann-Bichler
- Palliative Care, Konventhospital Barmherzige Brüder Linz, Linz, Österreich
| | - J Pihringer
- Palliative Care, Konventhospital Barmherzige Brüder Linz, Linz, Österreich
| | - F Firlinger
- Abteilung für Innere Medizin und Intensivmedizin, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
| | - A Pickl
- Palliative Care, Konventhospital Barmherzige Brüder Linz, Linz, Österreich
| | - M Clodi
- Abteilung für Innere Medizin und Intensivmedizin, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
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91
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Sipples R, Taylor R, Kirk-Walker D, Bagcivan G, Dionne-Odom JN, Bakitas M. Perioperative Palliative Care Considerations for Surgical Oncology Nurses. Semin Oncol Nurs 2017; 33:9-22. [DOI: 10.1016/j.soncn.2016.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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92
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Higginson IJ, Reilly CC, Bajwah S, Maddocks M, Costantini M, Gao W. Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors. BMC Med 2017; 15:19. [PMID: 28143520 PMCID: PMC5286738 DOI: 10.1186/s12916-016-0776-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital. METHODS This population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001-2004), first strategy phase (2004-2008), and strategy intensification (2009-2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs). RESULTS Over 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004-2005, hospital deaths fell (PRs 0.92-0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01-1.55) than COPD (PRs 1.01-1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94-0.94) or outside London (PRs, 0.89-0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65-74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89-1.04); in COPD, hospital death was associated with being married. CONCLUSIONS The EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.
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Affiliation(s)
- Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Charles C. Reilly
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Massimo Costantini
- Arcispedale Santa Maria Nuova-IRCCS, Viale Umberto I, 50 – 42123, Reggio Emilia, Italy
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - on behalf of the GUIDE_Care project
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
- Arcispedale Santa Maria Nuova-IRCCS, Viale Umberto I, 50 – 42123, Reggio Emilia, Italy
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93
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Hua M. Palliative Care. Oncology 2017. [DOI: 10.4018/978-1-5225-0549-5.ch001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Palliative care is a specialty of medicine that focuses on improving quality of life for patients with serious illness and their families. As the limitations of intensive care and the long-term sequelae of critical illness continue to be delimited, the role of palliative care for patients that are unable to achieve their original goals of care, as well as for survivors of critical illness, is changing and expanding. The purpose of this chapter is to introduce readers to the specialty of palliative care and its potential benefits for critically ill patients, and to present some of the issues related to the delivery of palliative care in surgical units.
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94
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Utilization of palliative care services for cardiac arrest patients undergoing therapeutic hypothermia: A retrospective analysis. Resuscitation 2016; 112:22-27. [PMID: 28011292 DOI: 10.1016/j.resuscitation.2016.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/30/2016] [Accepted: 12/09/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Palliative care (PC) services are integral to the care of patients with advanced medical illnesses. Given the significant morbidity and mortality associated with cardiac arrest, we sought to measure the use and impact of PC in the care of patients treated with therapeutic hypothermia (TH). METHODS We conducted a retrospective study of 317 consecutive patients undergoing TH after cardiac arrest. We compared intensive care unit (ICU) characteristics and clinical outcomes of subjects who received PC consultation (n=125) to those who did not (n=192). RESULTS The proportion of TH patients with PC consultations increased to greater than 60% by 2013, corresponding to our institution's expansion of PC services, development of a dedicated PC unit, and integration of this service into our published TH protocol. In the TH population, time to return of spontaneous circulation (ROSC) was associated with higher inpatient mortality (p<0.001) and placement of a PC consult (p=0.011). TH patients who received PC consultation had longer ICU stays (p=0.034), more ventilator days (p<0.001), and higher inpatient mortality (p<0.001). When these measures were analyzed cohort-wide comparing all TH patients pre- and post-2013, at which time the frequency of PC consultation had dramatically increased, there were no statistically significant differences in ICU care or outcomes. CONCLUSION In our population of cardiac arrest patients undergoing TH, the utilization of PC services has increased over time, particularly for those patients with high morbidity and mortality. Future randomized studies may further delineate optimal patient selection for PC consultation to better facilitate goals of care discussions and timely medical decision-making.
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95
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Turnbull AE, Sahetya SK, Needham DM. Aligning critical care interventions with patient goals: A modified Delphi study. Heart Lung 2016; 45:517-524. [PMID: 27593494 PMCID: PMC5887162 DOI: 10.1016/j.hrtlng.2016.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To develop a list of non-emergent, potentially harmful interventions commonly performed in ICUs that require a clear understanding of patients' treatment goals. BACKGROUND A 2016 policy statement from the American Thoracic Society and American College of Critical Care Medicine calls on intensivists to engage in shared decision-making when "making major treatment decisions that may be affected by personal values, goals, and preferences." METHODS A three-round modified Delphi consensus process was conducted via a panel of 6 critical care physicians, 6 ICU nurses, 6 former ICU patients, and 6 family members from 6 academic and community-based medical institutions in the U.S. mid-Atlantic region. RESULTS Recommendations about 8 interventions achieved consensus among respondents. CONCLUSIONS Clinical and patient/family participants in a modified Delphi consensus process were able to identify preference-sensitive decisions that should trigger clinicians to clarify patient goals and consider initiating shared decision-making.
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Affiliation(s)
- Alison E Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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96
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Palliative Care and Intensive Care Units. J Hosp Palliat Nurs 2016. [DOI: 10.1097/njh.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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97
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Bergman J, Laviana AA. Opportunities to maximize value with integrated palliative care. J Multidiscip Healthc 2016; 9:219-26. [PMID: 27226721 PMCID: PMC4863682 DOI: 10.2147/jmdh.s90822] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Palliative care involves aggressively addressing and treating psychosocial, spiritual, religious, and family concerns, as well as considering the overall psychosocial structures supporting a patient. The concept of integrated palliative care removes the either/or decision a patient needs to make: they need not decide if they want either aggressive chemotherapy from their oncologist or symptom-guided palliative care but rather they can be comanaged by several clinicians, including a palliative care clinician, to maximize the benefit to them. One common misconception about palliative care, and supportive care in general, is that it amounts to “doing nothing” or “giving up” on aggressive treatments for patients. Rather, palliative care involves very aggressive care, targeted at patient symptoms, quality-of-life, psychosocial needs, family needs, and others. Integrating palliative care into the care plan for individuals with advanced diseases does not necessarily imply that a patient must forego other treatment options, including those aimed at a cure, prolonging of life, or palliation. Implementing interventions to understand patient preferences and to ensure those preferences are addressed, including preferences related to palliative and supportive care, is vital in improving the patient-centeredness and value of surgical care. Given our aging population and the disproportionate cost of end-of-life care, this holds great hope in bending the cost curve of health care spending, ensuring patient-centeredness, and improving quality and value of care. Level 1 evidence supports this model, and it has been achieved in several settings; the next necessary step is to disseminate such models more broadly.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Veterans Health Affairs-Greater Los Angeles, Los Angeles, CA, USA
| | - Aaron A Laviana
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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98
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Finkelstein M, Goldstein NE, Horton JR, Eshak D, Lee EJ, Kohli-Seth R. Developing triggers for the surgical intensive care unit for palliative care integration. J Crit Care 2016; 35:7-11. [PMID: 27481729 DOI: 10.1016/j.jcrc.2016.04.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Despite the growing acceptance of palliative care as a component of high-quality care for patients with serious illness, it remains underutilized in the surgical critical care setting. This article provides insight into a model for palliative care integration into the surgical intensive care unit (SICU), using triggers. METHODS We performed a prospective cohort study after the implementation of a new set of palliative care triggers in the SICU of an 1170-bed tertiary medical center over the course of 9 months. We aimed to determine the ability of these triggers to identify patients who would benefit from palliative care consultation. RESULTS There were 517 SICU admissions during the period of interest. Of this cohort, patients who had not yet been discharged at the time of analysis were excluded (n=25), and the remaining underwent analysis (n=492). Factors significantly associated with hospital death or hospice discharge were repeat SICU admission, metastatic/advanced cancer, SICU physician referral, and the matching of 2 or more secondary criteria. CONCLUSIONS A series of triggers can help identify patients who may benefit from palliative care consultation. This approach can be used in intensive care settings to facilitate palliative care integration.
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Affiliation(s)
| | - Nathan E Goldstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatrics Research Education and Clinical Care Center, James J Peters VA Medical Center, Bronx, NY
| | - Jay R Horton
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David Eshak
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric J Lee
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Roopa Kohli-Seth
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
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99
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Radcliffe C, Hewison A. Use of a supportive care pathway for end-of-life care in an intensive care unit: a qualitative study. Int J Palliat Nurs 2016; 21:608-15. [PMID: 26707490 DOI: 10.12968/ijpn.2015.21.12.608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Providing palliative care support in intensive care settings is beneficial, however, barriers to delivering high-quality end-of-life care remain. To address this, pathways have been used to improve the quality of palliative care in generalist settings. This study describes the views of health professionals using a supportive care pathway in intensive care. DESIGN Qualitative semi-structured interviews were conducted with ten health professionals working in a surgical intensive care unit. The data were analysed thematically. RESULTS Participants were positive about the effect of the supportive care pathway on patient care, particularly in enabling consensus in care planning. Some expressed concerns including the difficulty of identifying the 'correct patients' for the pathway, the risk of it becoming a 'self-fulfilling prophecy', and a euphemism for dying. CONCLUSION Pathways are one potential mechanism for guiding care planning and communicating the goals of care to colleagues, patients and families, thus contributing to improvements in palliative care.
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Affiliation(s)
| | - Alistair Hewison
- Senior Lecturer, Department of Nursing, School of Health and Population Sciences, University of Birmingham, UK
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100
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O’Mahony S, Johnson TJ, Amer S, McHugh ME, McHenry J, Fosler L, Kvetan V. Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams. Am J Hosp Palliat Care 2016; 34:330-334. [DOI: 10.1177/1049909115627425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. Objective: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. Methods: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. Results: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. Conclusion: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.
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Affiliation(s)
- Sean O’Mahony
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Tricia J. Johnson
- Department of Health Systems Management, Rush University, Chicago, IL, USA
| | - Shawn Amer
- Department of Health Systems Management, Rush University, Chicago, IL, USA
- Palliative Care Service, OhioHealth, Columbus, OH, USA
| | - Marlene E. McHugh
- College of Nursing, Columbia University Medical Center, New York City, NY, USA
| | - Janet McHenry
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Laura Fosler
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Vladimir Kvetan
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
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