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Morrison ML. Patient decision-making in left ventricular assist devices for destination therapy. Int J Palliat Nurs 2024; 30:108-117. [PMID: 38517852 DOI: 10.12968/ijpn.2024.30.3.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
BACKGROUND Heart failure is a common life-limiting disease. A destination therapy for people who will not have a heart transplant is a left ventricular assist device. AIMS To discover how patients who have a left ventricular assist device for destination therapy make decisions about their healthcare after implantation of the device. METHODS A descriptive qualitative design with semi-structured, in-depth interviews with 11 participants who are living with a left ventricular assist device for destination therapy. FINDINGS People with a left ventricular assist device felt they had 'no choice' when making decisions about their healthcare. CONCLUSION Engaging with patients to contemplate present and future healthcare decisions is a complex process that includes cognitive processes within the patient. Clinicians need to be aware that a gap may occur between what is said and what is heard in communication.
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Affiliation(s)
- Megan L Morrison
- Nurse Practitioner, Palliative and Geriatric Medicine Inova Fairfax Hospital, US
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2
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Andresen H, Pagonas N, Eisert M, Patschan D, Nordbeck P, Buschmann I, Sasko B, Ritter O. Defibrillator exchange in the elderly. Heart Rhythm O2 2023; 4:382-390. [PMID: 37361620 PMCID: PMC10288028 DOI: 10.1016/j.hroo.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background Implantable cardioverter-defibrillator (ICD) therapy in elderly patients is controversial because survival benefits might be attenuated by nonarrhythmic causes of death. Objective The purpose of this study was to investigate the outcome of septuagenarians and octogenarians after ICD generator exchange (GE). Methods A total of 506 patients undergoing elective GE were analyzed to determine the incidence of ICD shocks and/or survival after GE. Patients were divided into a septuagenarian group (age 70-79 years) and an octogenarian group (age ≥80 years). The primary endpoint was death from any cause. Secondary endpoints were survival after appropriate ICD shock and death without experiencing ICD shocks after GE ("prior death"). Results The association of the ICD with all-cause mortality and arrhythmic death was determined for septuagenarians and octogenarians. Comparing both groups, similar left ventricular ejection fraction (35.6% ± 11.2% vs 32.4% ± 8.9%) and baseline prevalence of New York Heart Association functional class III or IV heart failure (17.1% vs 14.7%) were found. During the entire follow-up period of the study, 42.5% of patients in the septuagenarian group died compared to 79% in the octogenarian group (P <.01). Prior death was significantly more frequent in both age groups than were appropriate ICD shocks. Predictors of mortality were common in both groups and included advanced heart failure, peripheral arterial disease, and renal failure. Conclusion In clinical practice, decision-making for ICD GE among the elderly should be considered carefully for individual patients.
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Affiliation(s)
- Henrike Andresen
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
| | - Nikolaos Pagonas
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
| | - Marius Eisert
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
| | - Daniel Patschan
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg/Havel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Ivo Buschmann
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg/Havel, Germany
| | - Benjamin Sasko
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Department of Internal Medicine IV–Cardiology, Knappschaftskrankenhaus Bottrop, Bottrop, Germany
| | - Oliver Ritter
- Department of Internal Medicine I, Klinikum Brandenburg, Brandenburg/Havel, Germany
- Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg/Havel, Germany
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3
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Murthy S, Clapp JT, Burson RC, Fleisher LA, Neuman MD. Physicians' perspectives of prognosis and goals of care discussions after hip fracture. J Am Geriatr Soc 2022; 70:1487-1494. [PMID: 34990017 PMCID: PMC9106823 DOI: 10.1111/jgs.17642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hip fracture often represents a major transition in patients' health, with a 1-year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence. METHODS We conducted qualitative, semi-structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy. RESULTS Physicians agreed that hip fracture had a considerable 1-year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in-depth conversations in a busy perioperative setting. CONCLUSION Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.
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Affiliation(s)
- Sushila Murthy
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall C Burson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Gould KR, Ponsford JL, Hicks AJ, Hopwood M, Renison B, Feeney TJ. Positive behaviour support for challenging behaviour after acquired brain injury: An introduction to PBS + PLUS and three case studies. Neuropsychol Rehabil 2019; 31:57-91. [PMID: 31446844 DOI: 10.1080/09602011.2019.1656647] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Challenging behaviours are a common and distressing consequence of acquired brain injury (ABI). There are no evidence-based guidelines for managing challenging behaviours after ABI, leaving clinicians with few resources to guide practice. Findings from case studies and single-subject experimental designs support the use of positive behaviour support (PBS) interventions for challenging behaviour post-ABI. This paper introduces PBS + PLUS: a multi-component and flexible PBS intervention using a person-driven collaborative approach to build a meaningful life and self-regulate behaviour after ABI. PBS + PLUS is currently being examined in a randomized controlled trial (RCT). Three detailed pilot case studies illustrate the highly individualized implementation of the programme, delivered to the individuals with ABI and carers over 12 months by a transdisciplinary team including neuropsychologists, occupational therapists, and psychiatrists. Objective behavioural outcomes are reported for participants using the Overt Behaviour Scale at baseline and four-monthly intervals for two years. Goal attainment scaling was used to measure personally meaningful goals. The qualitative appraisals of the intervention by participants, families and carers, and 12-month follow-up outcomes are described. The advantages and challenges of programme delivery are discussed. These case studies will assist clinicians and service providers to implement PBS + PLUS in anticipation of the results of the RCT.
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Affiliation(s)
- Kate Rachel Gould
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Jennie Louise Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Albert Road Clinic, Melbourne, Australia
| | - Belinda Renison
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - Timothy J Feeney
- Belvedere Health Services and the Mill School, Essex Junction, VT, USA
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5
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Thylén I, Moser DK, Strömberg A. Octo- and nonagenarians' outlook on life and death when living with an implantable cardioverter defibrillator: a cross-sectional study. BMC Geriatr 2018; 18:250. [PMID: 30342484 PMCID: PMC6195969 DOI: 10.1186/s12877-018-0942-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 10/10/2018] [Indexed: 12/16/2022] Open
Abstract
Background Elderly individuals are increasingly represented among patients with implantable cardioverter defibrillators (ICD), but data describing life with an ICD are scarse among octo- and nonagenarians. Moreover, few studies have reported those elderly patients’ perspective on timly discussions concerning what shock deactivation involves, preferences on battery replacement, and their attitudes about turning off the ICD nearing end-of-life. Consequently, the aim of the study was to describe outlooks on life and death in octo- and nonagenarian ICD-recipients. Methods Participants were identified via the Swedish Pacemaker- and ICD-registry, with 229 octo- and nonagenarians (82.0 ± 2.2 years, 12% female) completing the survey on one occasion. The survey involved questions on health and psychological measures, as well as on experiences, attitudes and knowledge of end-of-life issues in relation to the ICD. Results The majority (53%) reported their existing health as being good/very good and rated their health status as 67 ± 18 on the EuroQol Visual Analog Scale. A total of 34% had experienced shock(s), 11% suffered from symptoms of depression, 15% had anxiety, and 26% reported concerns related to their ICD. About one third (34%) had discussed their illness trajectory with their physician, with those octo- and nonagenarians being more decisive about a future deactivation (67% vs. 43%, p < .01). A minority (13%) had discussed what turning off shocks would involve with their physician, and just 7% had told their family their wishes about a possible deactivation in the future. The majority desired battery replacement even if they had reached a very advanced age when one was needed (69%), or were seriously ill with a life-threatening disease (55%). When asked about deactivation in an anticipated terminal illness, about one third (34%) stated that they wanted to keep the shocks in the ICD during these circumstances. About one-fourth of the octo- and nonagenarians had insufficient knowledge regarding the ethical aspects, function of the ICD, and practical consequences of withdrawing the ICD treatment in the end-of-life. Conclusions Increasing numbers of elderly persons receive an ICD and geriatric care must involve assessments of life expectancy as well as the patient’s knowledge and attitudes in relation to generator changes and deactivation.
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Affiliation(s)
- Ingela Thylén
- Department of Cardiology and Department of Medical and Health Sciences, Division of Nursing Sciences, Linköping University, S-581 83, Linköping, Sweden.
| | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington, USA
| | - Anna Strömberg
- Department of Cardiology and Department of Medical and Health Sciences, Division of Nursing Sciences, Linköping University, S-581 83, Linköping, Sweden.,Sue and Bill Gross School of Nursing, University of California, Irvine, USA
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Goldstein NE, Kalman J, Kutner JS, Fromme EK, Hutchinson MD, Lipman HI, Matlock DD, Swetz KM, Lampert R, Herasme O, Morrison RS. A study to improve communication between clinicians and patients with advanced heart failure: methods and challenges behind the working to improve discussions about defibrillator management trial. J Pain Symptom Manage 2014; 48:1236-46. [PMID: 24768595 PMCID: PMC4205212 DOI: 10.1016/j.jpainsymman.2014.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Abstract
We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA.
| | - Jill Kalman
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erik K Fromme
- Departments of Medicine, Radiation Medicine, and Nursing, Oregon Health Sciences University, Portland, Oregon, USA
| | - Mathew D Hutchinson
- Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah I Lipman
- Divisions of Geriatrics and Cardiology, Montefiore Medical Center, Bronx, New York, USA; The Montefiore-Einstein Center for Bioethics, Montefiore Medical Center, Bronx, New York, USA
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachel Lampert
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Omarys Herasme
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
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Azoulay E, Chaize M, Kentish-Barnes N. Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care 2014; 4:37. [PMID: 25593753 PMCID: PMC4273688 DOI: 10.1186/s13613-014-0037-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/06/2014] [Indexed: 11/10/2022] Open
Abstract
Families of patients are not simple visitors to the ICU. They have just been separated from a loved one, often someone they live with, either abruptly or, in nearly half the cases, because a chronic condition has suddenly worsened. They must cope with a serious illness of a loved one, while having to adapt to the unfamiliar and intimidating ICU environment. In many cases, the outcome of the critical illness is uncertain, a situation that causes considerable distress to the relatives. As shown by our research group and others, families exhibit symptoms of anxiety (70%) and depression (35%) in the first few days after admission, as well as symptoms of stress (33%) and difficulty understanding the information delivered by the healthcare staff (50%). Furthermore, relatives of patients who die in the ICU are at risk for psychiatric syndromes such as generalized anxiety, panic attacks, depression, and posttraumatic stress syndrome. In this setting of psychological distress, families are asked to consider sharing in healthcare decisions about their loved one in the ICU. This article aims to foster the debate about the shared decision-making process. We have three objectives: to transcend the overly simplistic position that opposes paternalism and autonomy, to build a view founded only on an evaluation of actual practice and experience in the field, and to keep the focus squarely on the patient. Families want information and communication time from the staff. Nurses and physicians need to understand that families can share in decisions only if the entire ICU staff actively promotes family involvement and, of course, if the family wants to participate in all or part of the decision-making process.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Marine Chaize
- Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Nancy Kentish-Barnes
- Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
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McIlvennan CK, Allen LA, Nowels C, Brieke A, Cleveland JC, Matlock DD. Decision making for destination therapy left ventricular assist devices: "there was no choice" versus "I thought about it an awful lot". Circ Cardiovasc Qual Outcomes 2014; 7:374-80. [PMID: 24823949 DOI: 10.1161/circoutcomes.113.000729] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Destination therapy left ventricular assist devices (DT LVADs) are one of the most invasive medical interventions for end-stage illness. How patients decide whether or not to proceed with device implantation is unknown. We aimed to understand the decision-making processes of patients who either accept or decline DT LVADs. METHODS AND RESULTS Between October 2012 and September 2013, we conducted semistructured, in-depth interviews to understand patients' decision-making experiences. Data were analyzed using a mixed inductive and deductive approach. Twenty-two eligible patients were interviewed, 15 with DT LVADs and 7 who declined. We found a strong dichotomy between decision processes with some patients (11 accepters) being automatic and others (3 accepters, 7 decliners) being reflective in their approach to decision making. The automatic group was characterized by a fear of dying and an over-riding desire to live as long as possible: "[LVAD] was the only option I had…that or push up daisies…so I automatically took this." By contrast, the reflective group went through a reasoned process of weighing risks, benefits, and burdens: "There are worse things than death." Irrespective of approach, most patients experienced the DT LVAD decision as a highly emotional process and many sought support from their families or spiritually. CONCLUSIONS Some patients offered a DT LVAD face the decision by reflecting on a process and reasoning through risks and benefits. For others, the desire to live supersedes such reflective processing. Acknowledging this difference is important when considering how to support patients who are faced with this complex decision.
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Affiliation(s)
- Colleen K McIlvennan
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.).
| | - Larry A Allen
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.)
| | - Carolyn Nowels
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.)
| | - Andreas Brieke
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.)
| | - Joseph C Cleveland
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.)
| | - Daniel D Matlock
- From the Section of Advanced Heart Failure and Transplantation, Division of Cardiology (C.K.M., L.A.A., A.B.), Division of General Internal Medicine (C.N., D.D.M.), and Division of Cardiothoracic Surgery (J.C.C.), University of Colorado School of Medicine, Aurora; and Colorado Cardiovascular Outcomes Research Consortium, Denver (C.K.M., L.A.A., D.D.M.)
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Capsule commentary on Betz et al., "I wish we could normalize driving health": a qualitative study of clinician discussions with older drivers. J Gen Intern Med 2013; 28:1644. [PMID: 23797919 PMCID: PMC3832717 DOI: 10.1007/s11606-013-2515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Svarovsky T. Having Difficult Conversations: The Advanced Practitioner's Role. J Adv Pract Oncol 2013; 4:47-52. [PMID: 25031980 PMCID: PMC4093369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Throughout the course of their disease, patients with cancer and their families look to the oncology advanced practitioner (AP) for support and guidance as they struggle with the emotional impact of a life-limiting illness, complex treatment decisions, and the challenge of sustaining hope while maintaining realistic goals. At various points along the disease trajectory, difficult conversations between the AP and the patient are essential. In this case report of a 43-year-old woman with metastatic breast cancer, we model the use of various strategies available for the AP to help make these difficult conversations as productive, relevant, and emotionally safe for the patient as possible.
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Lampert R. Quality of Life and End-Of-Life Issues for Older Patients with Implanted Cardiac Rhythm Devices. Clin Geriatr Med 2012; 28:693-702. [DOI: 10.1016/j.cger.2012.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012; 125:1928-52. [PMID: 22392529 PMCID: PMC3893703 DOI: 10.1161/cir.0b013e31824f2173] [Citation(s) in RCA: 606] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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15
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Waldrop DP, Meeker MA. Hospice decision making: diagnosis makes a difference. THE GERONTOLOGIST 2012; 52:686-97. [PMID: 22387234 DOI: 10.1093/geront/gnr160] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision. METHODS This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36 hospice patients and 55 caregivers after 2 weeks of hospice care. The study was guided by Janis and Mann's conflict theory model (CTM) of decision making. Qualitative data analysis involved a directed content analysis using concepts from the CTM. RESULTS A model of hospice enrollment decision making is presented. Concepts from the CTM (appraisal, surveying and weighing the alternatives, deliberations, adherence) were used as an organizing framework to illustrate the dynamics. Distinct differences were found by diagnosis (cancer vs. other chronic illness, e.g., heart and lung diseases) during the pre-encounter phase or before the hospice referral but no differences emerged during the post-encounter phase. IMPLICATIONS Differences in decision making by diagnosis suggest the need for research about effective means for tailored communication in end-of-life decision making by type of illness. Recognition that decision making about hospice admission varies is important for clinicians who aim to provide person-centered and family-focused care.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, 685 Baldy Hall, Buffalo, NY 14260, USA.
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Surrogate decision makers: What if a surrogate cannot decide? JAAPA 2012; 25:61-2. [DOI: 10.1097/01720610-201202000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schonberg MA, Silliman RA, McCarthy EP, Marcantonio ER. Factors noted to affect breast cancer treatment decisions of women aged 80 and older. J Am Geriatr Soc 2012; 60:538-44. [PMID: 22283600 DOI: 10.1111/j.1532-5415.2011.03820.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To identify factors that influence the breast cancer treatment decisions of women aged 80 and older. DESIGN Medical record review. SETTING One academic primary care clinic and two community health centers in Boston. PARTICIPANTS Sixty-five women aged 80 and older diagnosed with breast cancer between 1994 and 2004 and followed through June 30, 2010. MEASUREMENTS Data were abstracted on breast cancer characteristics, comorbidities, treatments received, and outcomes. Notes from primary care physicians, oncologists, and breast surgeons were reviewed to determine factors involved in treatment decision-making. RESULTS Median age at diagnosis was 84.0 (interquartile range 82.0-86.3), 55 (84.6%) were non-Hispanic white, and 40 (61.5%) had at least one comorbidity. Nine women were diagnosed with ductal carcinoma in situ, 42 with a new primary invasive breast cancer, eight with a second primary, and six with a breast cancer recurrence. Sixty-three (96.9%) received some type of treatment. Fifty-six (86.2%) had at least one detailed physician note on treatment decision-making in their charts. The main categories found to influence participant, family, and physician treatment decision-making were tumor characteristics, ratio of treatment benefits to risks, logistics (e.g., transportation, finances), and participant age, health (including a concurrent diagnosis), and psychosocial characteristics. Family was involved in treatment discussions for 46 (70.8%) participants. CONCLUSION The quality of physician documentation about decision-making in these women was high. A great amount of thoughtful and complex decision-making involving patients, family, and physicians occurs after a woman aged 80 and older is diagnosed with breast cancer.
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Affiliation(s)
- Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Division of General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts, USA.
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Kramer DB, Brock DW, Tedrow UB. Informed consent in cardiac resynchronization therapy: what should be said? Circ Cardiovasc Qual Outcomes 2012; 4:573-7. [PMID: 21934080 DOI: 10.1161/circoutcomes.111.961680] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA 02446, USA.
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Gruenewald DA. Can health care rationing ever be rational? THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2012; 40:17-25. [PMID: 22458458 DOI: 10.1111/j.1748-720x.2012.00641.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Americans' appetite for life-prolonging therapies has led to unsustainable growth in health care costs. It is tempting to target older people for health care rationing based on their disproportionate use of health care resources and lifespan already lived, but aged-based rationing is unacceptable to many. Systems reforms can improve the efficiency of health care and may lessen pressure to ration services, but difficult choices still must be made to limit expensive, marginally beneficial interventions. In the absence of agreement on principles to govern health care resource allocation, a fair, open priority-setting process should be created to allow for reasonable disagreement on principles while being seen as legitimate by all stakeholders. At the patient-care level, careful discussions about the benefits and burdens of medical intervention and support for slow medicine - a gentle, family-centered care approach for frail elders - can do much to avoid harming these patients with aggressive yet unwanted medical care while reducing wasteful spending.
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Reckrey JM, Diane McKee M, Sanders JJ, Lipman HI. Resident Physician Interactions with Surrogate Decision-Makers: The Resident Experience. J Am Geriatr Soc 2011; 59:2341-6. [DOI: 10.1111/j.1532-5415.2011.03728.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine; Mount Sinai School of Medicine; New York; New York
| | - M. Diane McKee
- Department of Family and Social Medicine; Albert Einstein College of Medicine; Bronx; New York
| | - Justin J. Sanders
- Department of Family and Social Medicine; Montefiore Medical Center; Bronx; New York
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Matlock DD, Keech TAE, McKenzie MB, Bronsert MR, Nowels CT, Kutner JS. Feasibility and acceptability of a decision aid designed for people facing advanced or terminal illness: a pilot randomized trial. Health Expect 2011; 17:49-59. [PMID: 22032553 DOI: 10.1111/j.1369-7625.2011.00732.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients nearing the end of their lives face an array of difficult decisions. OBJECTIVE This study was designed to assess the feasibility and acceptability of a decision aid (DA) designed for patients facing advanced or terminal illness. DESIGN We conducted a pilot randomized clinical trial of Health Dialog's Looking Ahead: choices for medical care when you're seriously ill DA (booklet and DVD) applied to patients on a hospital-based palliative care (PC) service. SETTING University of Colorado Hospital - December 2009 and May 2010. PARTICIPANTS All adult, English-speaking patients or their decision makers were potentially eligible. Patients were not approached if they were in isolation, did not speak English or if any provider felt that they were not appropriate because of issues such as family conflict or actively dying. INTERVENTION All participants received a standard PC consultation. Participants in the intervention arm also received a copy of the DA. Measurements Primary outcomes included decision conflict and knowledge. Participants in the intervention arm also completed an acceptability questionnaire and qualitative exit interviews. RESULTS Of the 239 patients or decision makers, 51(21%) enrolled in the trial. The DA had no significant effect on decision conflict or knowledge. Exit interviews indicated it was acceptable and empowering, although they wished they had access to the DA earlier. CONCLUSIONS While the DA was acceptable, feasibility was limited by late-life illness challenges. Future trials of this DA should be performed on patients earlier in their illness trajectory and should include additional outcome measures such as self-efficacy and confidence.
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Affiliation(s)
- Dan D Matlock
- Department of Medicine, University of Colorado School of MedicineColorado Health Outcomes Program, University of Colorado School of Medicine, Aurora CO, USA
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Goldstein NE, May CW, Meier DE. Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care. Circ Heart Fail 2011; 4:519-27. [PMID: 21772016 PMCID: PMC3158989 DOI: 10.1161/circheartfailure.110.957241] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Nathan E Goldstein
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Desai AK, Grossberg GT. Palliative and end-of-life care in psychogeriatric patients. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A rapidly growing number of elderly persons and their families are burdened by one or more terminal illnesses in the later years of their life. How best to support their quality of life is a major challenge for healthcare teams. Palliative and end-of-life (PEOL) care is well positioned to respond to this challenge. While the evidence of PEOL is just beginning, much of the suffering can be relieved by what is already known. PEOL care for the elderly needs to go beyond the focus on the patient and should rest on a broad understanding of the nature of suffering that includes family and professional caregivers in that experience of suffering. The dissemination of PEOL care principles should be a public health priority. This article aims to improve understanding of appropriate PEOL care in the elderly and discuss future perspectives.
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Affiliation(s)
- Abhilash K Desai
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 S. Grand Blvd, St Louis, MO 63104, USA
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Melhado L, Bushy A. Exploring Uncertainty in Advance Care Planning in African Americans. Am J Hosp Palliat Care 2011; 28:495-500. [DOI: 10.1177/1049909110398005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
African Americans over 65 represent 3.5 of the 35.6 million Americans. Morbidity and mortality rates are highest among this group; associated with lack of resources and awareness of health problems. But health needs are the same at end of life, yet care is less than optimal. African Americans are less likely to have advance directives nonetheless desire communication, information, respect, and a trusting doctor-patient relationship. Low health literacy may contribute to this disparity. This scholarly review examines the health literacy in advance care planning and refines concepts of uncertainty in illness theory deriving a model for advance care planning in African Americans.
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Affiliation(s)
- Lolita Melhado
- Lee Memorial Health System, Gulf Coast Medical Center, FL, USA
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Jacobsen J, Robinson E, Jackson VA, Meigs JB, Billings JA. Development of a cognitive model for advance care planning discussions: results from a quality improvement initiative. J Palliat Med 2011; 14:331-6. [PMID: 21247300 DOI: 10.1089/jpm.2010.0383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Residents struggle with advance care planning (ACP) discussions in the inpatient setting, and may not be aware of newer models for ACP that stress the importance of giving prognostic information and making a recommendation about cardiopulmonary resuscitation to patients and families. METHODS A controlled study of a cognitive model for ACP embedded in a quality improvement (QI) project. RESULTS In the setting of a QI project for medical residents and interdisciplinary staff, we developed and implemented a cognitive model of ACP discussions that involved two types of meetings for patients: (1) information-sharing meetings for seriously ill but clinically stable patients and (2) decision-making meetings for clinically unstable patients. Patients on the intervention floor were significantly more likely to have a discussion about goals of care (33.8%) than patients on the control floor (21.2%, p = < 0.001) and significantly more likely to have a limitation of life-sustaining treatment upon discharge (19.1% vs. 13.9%, p = 0.04). CONCLUSIONS For both residents and interdisciplinary staff, application of a cognitive model that clearly defines goals and expectations for ACP discussions prior to meeting with patients and families improves rates of ACP discussions.
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Affiliation(s)
- Juliet Jacobsen
- Palliative Care Service, Massachusetts General Hospital , Boston, MA 02114, USA.
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Epner DE, Baile WF. Wooden's pyramid: building a hierarchy of skills for successful communication. MEDICAL TEACHER 2011; 33:39-43. [PMID: 21182381 DOI: 10.3109/0142159x.2010.530316] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND John Wooden, the legendary college basketball coach, created the "Pyramid of Success", which he constructed from 14 timeless character traits and interpersonal skills that are critical to competitive greatness. Wooden's pyramid is a powerful symbol that he and others have used for several decades as an educational tool to promote leadership and teamwork. AIM This article proposes the "Pyramid of Relational Excellence (PRE)", patterned after Wooden's pyramid, as a mnemonic-based educational symbol for communication skills training. METHOD Literature review, personal reflection. RESULTS The PRE is constructed of four tiers with a total of 12 building blocks, with each successive tier built upon the one beneath it. The building blocks represent fundamental elements that are known to be critical to successful communication. CONCLUSIONS The PRE is process oriented rather than task oriented and focuses exclusively on the face-to-face encounter. It therefore complements established communications curricula, such as the UK communication wheel and others, which are more comprehensive and task oriented. The PRE is constructed of timeless, fundamental principles. It is therefore particularly well suited for training medical students and residents.
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Affiliation(s)
- Daniel E Epner
- Department of General Oncology, MD Anderson Cancer Center, Houston, TX 77030, USA.
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Sudore RL, Fried TR. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Ann Intern Med 2010; 153:256-61. [PMID: 20713793 PMCID: PMC2935810 DOI: 10.7326/0003-4819-153-4-201008170-00008] [Citation(s) in RCA: 576] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, Veterans Affairs Medical Center, San Francisco, CA 94121, USA.
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Abstract
The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.
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Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton RM, Kay GN, Kramer DB, Mueller PS, Padeletti L, Pozuelo L, Schoenfeld MH, Vardas PE, Wiegand DL, Zellner R. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7:1008-26. [PMID: 20471915 DOI: 10.1016/j.hrthm.2010.04.033] [Citation(s) in RCA: 328] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Indexed: 10/19/2022]
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Escarrabill J, Soler Cataluña JJ, Hernández C, Servera E. [Recommendations for end-of-life care in patients with chronic obstructive pulmonary disease]. Arch Bronconeumol 2009; 45:297-303. [PMID: 19442429 DOI: 10.1016/j.arbres.2008.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 11/24/2008] [Indexed: 10/20/2022]
Affiliation(s)
- Joan Escarrabill
- Institut d'Estudis de la Salut, Departament de Salut, Barcelona, España.
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