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Morita K, Miyamoto Y, Mizuno A, Shirane S, Ohbe H, Hashimoto Y, Kaneko H, Matsui H, Fushimi K, Yasunaga H. Impact of a financial incentive scheme for team-based palliative care in patients with heart failure in Japan: A nationwide database study. Int J Cardiol 2023; 387:131145. [PMID: 37364713 DOI: 10.1016/j.ijcard.2023.131145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/05/2023] [Accepted: 06/23/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Palliative care provided to patients with heart failure (HF) are reported to be inadequate. Herein, we examined the impact of the recently introduced financial incentive scheme for team-based palliative care for patients with HF in acute care hospitals in Japan. METHODS Using a nationwide inpatient database, we identified patients aged ≥65 years with HF who had died between April 2015 and March 2021. Interrupted time-series analyses were used to compare practice patterns in end-of-life care (symptom management and invasive medical procedures within one week before death) before and after the financial incentive scheme issuance in April 2018. RESULTS Overall, 53,857 patients in 835 hospitals were eligible. The adoption of the financial incentive was 1.10 to 1.22% after the introduction. There were upward pre-trends in opioid use (+0.11% per month; 95% confidence interval [CI], 0.06 to 0.15) and antidepressant use (+0.06% per month; 95% CI, 0.04 to 0.09). Opioid use showed a downward slope change during the post-period (-0.07% change in trend; 95% CI, -0.13 to -0.01). Intensive care unit stay showed a downward pre-trend (-0.09% per month; 95% CI, -0.14 to -0.04) and upward slope changes during the post-period (+0.12% change in trend; 95% CI, 0.04 to 0.19). Invasive mechanical ventilation showed downward slope changes during the post-period (-0.11% change in trend; 95% CI, -0.18 to -0.04). CONCLUSIONS The financial incentive scheme for team-based palliative care was rarely adopted and not associated with changes in end-of-life care. Further multifaceted strategies to promote palliative care for HF are warranted.
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Affiliation(s)
- Kojiro Morita
- Global Nursing Research Center, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, QI center, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Sachie Shirane
- Department of Palliative Therapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan; Department of Palliative Care, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Ophthalmology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Advanced Cardiology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Factors Related to Care Managers' Experiences of Making Proxy Decisions about Older Adults Living Alone: A Cross-Sectional Study. NURSING REPORTS 2023; 13:57-66. [PMID: 36648980 PMCID: PMC9844272 DOI: 10.3390/nursrep13010006] [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: 11/15/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
In Japan, the number of older adults living alone who require nursing care continues to rise. The purpose of this study was to identify factors associated with care managers' experiences of making proxy decisions about life directions for older adults who live alone and whose intentions cannot be fully confirmed. The participants were care managers of in-home long-term care support providers nationwide. An original self-report questionnaire was created with reference to previous research and a web-based survey was conducted. The responses were obtained from 241 people and 211 people were included in the analysis. Two factors were identified that were related to care managers' experiences of proxy decision-making about the life direction of older adults living alone whose intentions could not be fully confirmed: the ability to perform administrative tasks (odds ratio [OR] 3.38, 95% confidence interval [CI]: 1.39-8.22) and the observed cognitive deterioration (OR 2.89, 95% CI: 1.06-7.83). Even if older adults living alone can independently perform administrative tasks, observed cognitive deterioration may be a prodromal sign that such adults will be unable to make decisions about their future life.
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Chen DR, Jerng JS, Tsai DFC, Young Y. Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse. Palliat Care 2022; 21:171. [PMID: 36203170 PMCID: PMC9534740 DOI: 10.1186/s12904-022-01062-8] [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] [Received: 04/28/2022] [Revised: 08/26/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self–other differences in the intention to withhold LSTs between genders. Methods Between March and October 2019, a structured questionnaire was distributed to hospitalized patients’ family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia. Results Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios. Conclusion Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.
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Affiliation(s)
- Duan-Rung Chen
- Institute of Health Behaviors and Community Sciences, National Taiwan University, Taipei, Taiwan.
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Fu-Chang Tsai
- Department & Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yuchi Young
- Department of Health Policy, Management & Behavior, School of Public Health, New York State University,, Albany, USA
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Gender- and age-based differences in outcomes of mechanically ventilated ICU patients: a Chinese multicentre retrospective study. BMC Anesthesiol 2022; 22:18. [PMID: 35012463 PMCID: PMC8744292 DOI: 10.1186/s12871-021-01555-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have suggested that the gender and/or age of a patient may influence the clinical outcomes of critically ill patients. Our aim was to determine whether there are gender- and age-based differences in clinical outcomes for mechanically ventilated patients in intensive care units (ICUs). METHODS We performed a multicentre retrospective study involving adult patients who were admitted to the ICU and received at least 24 h of mechanical ventilation (MV). The patients were divided into two groups based on gender and, subsequently, further grouped based on gender and age < or ≥ 65 years. The primary outcome measure was hospital mortality. RESULTS A total of 853 mechanically ventilated patients were evaluated. Of these patients, 63.2% were men and 61.5% were ≥ 65 years of age. The hospital mortality rate for men was significantly higher than that for women in the overall study population (P = 0.042), and this difference was most pronounced among elderly patients (age ≥ 65 years; P = 0.006). The durations of MV, ICU lengths of stay (LOS), and hospital LOS were significantly longer for men than for women among younger patients (P ≤ 0.013) but not among elderly patients. Multivariate logistic regression analysis revealed that male gender was independently associated with hospital mortality among elderly patients but not among younger patients. CONCLUSIONS There were important gender- and age-based differences in the outcomes among mechanically ventilated ICU patients. The combination of male gender and advanced age is strongly associated with hospital mortality.
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Higashitsuji A, Matsudo M, Majima T. Suffering and Attitudes Toward Death of Patients With Heart Failure in Japan: A Grounded Theory Approach. J Hosp Palliat Nurs 2021; 23:421-428. [PMID: 34369421 DOI: 10.1097/njh.0000000000000783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early palliative care is needed for patients with heart failure (HF). However, little is known about the suffering and attitudes toward death of these patients before they reach end-stage HF. This study aimed to identify the suffering and attitudes toward death of patients with early- and intermediate-stage HF. Our qualitative research process was guided with a grounded theory approach and consolidated criteria for reporting qualitative research. Participants were selected through theoretical sampling. Data were collected through semistructured interviews, participant observations, and medical records examination. The study included 10 patients. Analysis of the data revealed the core category of "evaluating whether HF hinders the current and future self." From this core category, 6 categories of causal conditions and 3 categories of consequences emerged. Participants with HF evaluated the causal conditions and suffering in the context of how they hindered the ideal state. After recognizing their own suffering, they expressed specific attitudes toward death. The 10 categories revealed in this study elucidate the process by which patients with HF form their attitudes toward death based on suffering. Health care professionals should consider these findings to help facilitate early palliative care interventions.
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Kitakata H, Kohno T, Kohsaka S, Fujisawa D, Nakano N, Shiraishi Y, Katsumata Y, Nagatomo Y, Yuasa S, Fukuda K. Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure. ESC Heart Fail 2021; 8:5102-5111. [PMID: 34480526 PMCID: PMC8712895 DOI: 10.1002/ehf2.13578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/07/2021] [Accepted: 08/11/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation. METHODS AND RESULTS Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients agreed to participate (response rate: 92.6%), and 171 completed the survey [valid response rate: 84.7%; men: 67.3%; median age: 73.0 (63.0-81.0) years]. Logistic regression analyses were conducted to identify the predictors of positive attitudes towards ACP. Most recognized ACP as important for their care (n = 127, 74.3%), 48.1% stated that ACP should be initiated after repeated HF hospitalizations in the past year, and 29.0% preferred ACP to begin during the first or second HF hospitalization. Only 21.7% of patients had previously engaged in ACP conversations during HF management. Positive attitudes towards ACP were associated with lower depressive symptoms [two-item Patient Health Questionnaire; odds ratio (OR): 0.75, 95% confidence interval (CI): 0.61-0.92, P-value: 0.006], marriage (OR: 2.53, 95% CI: 1.25-5.12, P-value: 0.010), and a high educational level (OR: 2.66, 95% CI: 1.28-5.56, P-value: 0.009), but not with severity of HF (represented by Seattle Heart Failure Model risk score). Regarding EOL care, while 'Saying what one wants to tell loved ones' (83.4%), 'Dying a natural death' (81.8%), and 'Being able to stay at one's favorite place' (75.6%) were the three most important factors for patients, preferences for 'Receiving sufficient treatment' (56.5%) and 'Knowing what to expect about future condition' (50.3%) were divergent. CONCLUSIONS Despite patients' preferences for ACP conversations, there was a discrepancy between preference and engagement in ACP among patients hospitalized for HF. Patients' preferences regarding EOL care may differ; physicians need to consider the appropriate ACP approach to align with patients' care goals.
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Affiliation(s)
- Hiroki Kitakata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.,Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, 6-20-2, Shinkawa, Mitaka, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Naomi Nakano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Katsumata
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Factors associated with surrogate families’ life-sustaining treatment preferences for patients at home or in a geriatric health service facility: A cross-sectional study. Palliat Support Care 2021; 20:334-341. [DOI: 10.1017/s1478951521001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Recently, end-of-life preference in palliative care has been gaining attention in Japan. The Ministry of Health, Labor, and Welfare established the Japanese basic policy in November 2018. Patients’ decision-making is recommended; however, patients with dementia or other disorders cannot make such decisions by themselves. Thus, healthcare providers may contact surrogates and consider their backgrounds for better decision-making. Hence, the preferences of home caregivers’ and geriatric health service facility (GHSF) residents’ families on patient life-sustaining treatment (LST) were investigated.
Method
This cross-sectional study involved home caregivers’ and GHSF residents’ families in Japan. We distributed 925 self-reported questionnaires comprising items, such as the number of people living together, care duration, comprehension of doctor's explanations, the Patient Health Questionnaire (PHQ)-9 and Short Form (SF)-8, and families’ LST preference for patients.
Results
In all, 619 valid responses were obtained [242 men and 377 women (309 in the HOME Caregivers Group, response rate = 61.1%; 310 in the GHSF Group, response rate = 74.0%)]. LST preference was significantly associated with sex, the number of people living together, care duration, and comprehension of doctors’ explanations in the HOME Caregivers Group but was not significantly associated with the GHSF Group. Furthermore, PHQ-9/SF-8 scores were not significantly associated with LST preference.
Significance of results
There were many differences in opinions about LST preference between home caregivers’ and GHSF residents’ families. The results suggested that the burden of nursing care was greater and harder in home caregiver families, and these factors may be related to the LST preference for a patient.
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Vogelsong MA, May T, Agarwal S, Cronberg T, Dankiewicz J, Dupont A, Friberg H, Hand R, McPherson J, Mlynash M, Mooney M, Nielsen N, O'Riordan A, Patel N, Riker RR, Seder DB, Soreide E, Stammet P, Xiong W, Hirsch KG. Influence of sex on survival, neurologic outcomes, and neurodiagnostic testing after out-of-hospital cardiac arrest. Resuscitation 2021; 167:66-75. [PMID: 34363853 DOI: 10.1016/j.resuscitation.2021.07.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/18/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
AIM Previous studies evaluating the relationship between sex and post-resuscitation care and outcomes following out-of-hospital cardiac arrest (OHCA) are conflicting. We investigated the association between sex and outcomes as well as neurodiagnostic testing in a prospective multicenter international registry of patients admitted to intensive care units following OHCA. METHODS OHCA survivors enrolled in the International Cardiac Arrest Registry (INTCAR) from 2012-2017 were included. We assessed the independent association between sex and survival to hospital discharge, good neurologic outcome (Cerebral Performance Category 1 or 2), neurodiagnostic testing, and withdrawal of life-sustaining therapy (WLST). RESULTS Of 2,407 eligible patients, 809 (33.6%) were women. Baseline characteristics differed by sex, with less bystander CPR and initial shockable rhythms among women. Women were less likely to survive to hospital discharge, however significance abated following adjusted analysis (30.1% vs 42.7%, adjusted OR 0.85, 95% CI 0.67-1.08). Women were less likely to have good neurologic outcome at discharge (21.4% vs 34.0%, adjusted OR 0.74, 95% CI 0.57-0.96) and at six months post-arrest (16.7% vs 29.4%, adjusted OR 0.73, 95% CI 0.54-0.98) that persisted after adjustment. Neuroimaging (75.5% vs 74.3%, p=0.54) and other neurophysiologic testing (78.8% vs 78.6%, p=0.91) was similar across sex. Women were more likely to undergo WLST (55.6% vs 42.8%, adjusted OR 1.35, 95% CI 1.09-1.66). CONCLUSIONS Women with cardiac arrest have lower odds of good neurologic outcomes and higher odds of WLST, despite comparable rates of neurodiagnostic testing and after controlling for baseline differences in clinical characteristics and cardiac arrest features.
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Affiliation(s)
- Melissa A Vogelsong
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States.
| | - Teresa May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center/New York Presbyterian Hospital, New York City, NY, United States Tobias Cronberg - Department of Clinical Sciences, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Allison Dupont
- Department of Cardiology, Northside Cardiovascular Institute, Atlanta, GA, United States
| | - Hans Friberg
- Department of Clinical Sciences, Intensive and Perioperative Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - John McPherson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael Mooney
- Department of Cardiology, Minneapolis Heart Institute, Abbot North-Western Hospital, Minneapolis, MN, United States
| | - Niklas Nielsen
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Andrea O'Riordan
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Nainesh Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, United States
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway, Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - Pascal Stammet
- Medical and Health Department, Luxembourg Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Wei Xiong
- Department of Neurology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
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Multidisciplinary Team-Based Palliative Care for Heart Failure and Food Intake at the End of Life. Nutrients 2021; 13:nu13072387. [PMID: 34371897 PMCID: PMC8308898 DOI: 10.3390/nu13072387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/17/2022] Open
Abstract
Traditionally, patients with end-stage heart failure (HF) have rarely been involved in end-of-life care (EOLC) discussions in Japan. The purpose of this study was to examine the impact of HF-specific palliative care team (HF-PCT) activities on EOLC discussions with patients, HF therapy and care, and food intake at the end of life. We retrospectively analyzed 52 consecutive patients with HF (mean age, 70 ± 15 years; 42% female) who died at our hospital between May 2013 and July 2020 and divided them into two groups: before (Era 1, n = 19) and after (Era 2, n = 33) the initiation of HF-PCT activities in June 2015. Compared to Era 1, Era 2 showed a decrease in invasive procedures, an increase in opioid and non-intubating sedative use for symptom relief, improved quality of meals at the end of life, and an increase in participation in EOLC discussions. The administration of artificial nutrition in the final three days was associated with non-ischemic cardiomyopathy etiology, the number of previous hospitalizations for HF, and multidisciplinary EOLC discussion support. HF-PCT activities may provide an opportunity to discuss EOLC with patients, reduce the burden of physical and psychological symptoms, and shift the goals of end-of-life nutritional intake to ensure comfort and quality of life.
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Shaku F, Yada Y, Tsutsumi M, Kim WS. Characterising end-of-life decision-making of life-sustaining treatment among Japanese nurses. Int J Palliat Nurs 2021; 27:213-218. [PMID: 34169740 DOI: 10.12968/ijpn.2021.27.4.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Often, nurses are closer to end-of-life (EOL) patients than other medical professionals, due to the time they spend with them at their bedside, which leads them to understand patients' care goals. AIMS To investigate the importance of EOL preferences by examining nurses' EOL decision-making regarding life-sustaining treatment (LST). METHODS In this cross-sectional study, 559 self-reported questionnaires of Japanese nurses were examined. Marital status, age and decision-making regarding LST for themselves were investigated. FINDINGS Unmarried participants from all age groups had a higher percentage of 'no preference for LST' than married groups. Differences between the percentages were higher in the 20s age group. Married participants increasingly preferred to receive no LST as their age increased, unlike single participants. CONCLUSION Marital status influences Japanese nurses' EOL decision-making regarding LST. Therefore, it is necessary to consider a patient's marital status to facilitate better decision-making.
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Affiliation(s)
- Fumio Shaku
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan; Department of Psychosomatic Internal Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Yoichi Yada
- Division of Pharmacology, Nihon University School of Medicine, Tokyo, Japan
| | | | - Woe Sook Kim
- College of Nursing Art and Science, University of Hyogo, Japan
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11
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Abe A, Kobayashi M, Kohno T, Takeuchi M, Hashiguchi S, Mimura M, Fujisawa D. Patient participation and associated factors in the discussions on do-not-attempt-resuscitation and end-of-life disclosure: a retrospective chart review study. BMC Palliat Care 2021; 20:6. [PMID: 33407388 PMCID: PMC7789264 DOI: 10.1186/s12904-020-00698-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022] Open
Abstract
Background Patient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients’ participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors. Methods This is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients’ involvement in those discussions, and their associated factors were investigated. Results CPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32–4.25]), living alone (OR = 2.51 [1.34–4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03–3.10]) were associated with higher patient’s participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45–4.03]) and patients without mental illness (OR=2.41 [1.11–5.25]) were more likely to participate in EOL disclosure. Conclusions In this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients’ participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients’ participation, based on their preference, are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-020-00698-8.
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Affiliation(s)
- Akiko Abe
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
| | - Masato Kobayashi
- Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Saori Hashiguchi
- Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Daisuke Fujisawa
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Division of Patient Safety, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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12
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Abstract
Heart failure (HF) is a complex clinical syndrome resulting from structural or functional cardiac disorders. In the developed world, HF is primarily a disorder of the elderly. It is one that is accompanied by many non-cardiac comorbidities that affect treatments given, the patient's response and treatment tolerance and outcomes. Even the pathophysiological mechanisms of HF change as we look at older patient populations. Younger HF patients typically have ischaemic heart disease and HF with reduced ejection fraction (HFrEF), whereas older patients have more hypertension HF with preserved ejection fraction (HFpEF). The prevalence of HF has progressively increased for many years and rises even more steeply with age. The outcomes of older especially HFpEF patients have not progressed as much younger HFrEF cohorts. We need more studies specifically recruiting older HF patients with more comorbidities, to guide real-world practice, and we need more assessment of patient-reported outcomes and quality of life rather than just mortality effects. The management of elderly patients with HF requires a more holistic approach recognizing individual needs and necessary support mechanisms and our future trials need to guide us more in achieving these gains.
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Affiliation(s)
- Andrew J Stewart Coats
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via di Val Cannuta 247, 00166 Roma, Italy
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13
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Coats AJS. Heart failure management of the elderly patient: focus on frailty, sarcopaenia, cachexia, and dementia: conclusions. Eur Heart J Suppl 2019; 21:L36-L38. [PMID: 31885512 PMCID: PMC6926414 DOI: 10.1093/eurheartj/suz236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 12/30/2022]
Abstract
With the ageing of populations heart failure is becoming more common and more complex. It is affecting ever older patients and the number of prevalent comorbidities is rising. Even as we continue to gain success in large-scale clinical trials with more effective therapies so our patients are becoming more complex. One of the biggest challenges is the effect of age. Frailty, comorbidity, sarcopaenia, cachexia, polypharmacy, and cognitive decline are all challenging our patients as never before and these challenges will be difficult for cash strapped health care systems to manage. For these reasons, the Heart Failure Association brought together a panel of experts to debate and review this complex area, championing the need for us to establish better ways of caring for the patients of the future.
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Affiliation(s)
- Andrew J Stewart Coats
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via di Val Cannuta 247, 00166 Roma, Italy
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14
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Tsuda K, Higuchi A, Yokoyama E, Kosugi K, Komatsu T, Kami M, Tanimoto T. Physician Decision-Making Patterns and Family Presence: Cross-Sectional Online Survey Study in Japan. Interact J Med Res 2019; 8:e12781. [PMID: 31493327 PMCID: PMC6764328 DOI: 10.2196/12781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 05/13/2019] [Accepted: 07/21/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Due to a low birth rate and an aging population, Japan faces an increase in the number of elderly people without children living in single households. These elderly without a spouse and/or children encounter a lack of caregivers because most sources of care for the elderly in Japan are not provided by private agencies but by family members. However, family caregivers not only help with daily living but are also key participants in treatment decision making. The effect of family absence on treatment decision making has not been elucidated, although more elderly people will not have family members to make surrogate decisions on their behalf. OBJECTIVE The aim is to understand the influence of family absence on treatment decision making by physicians through a cross-sectional online survey with three hypothetical vignettes of patients. METHODS We conducted a cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second was about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned to either of the two versions of the questionnaires-with family or without family-but methods were identical otherwise. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS Among 1112 physicians, 454 (40.8%) completed the survey; there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR] 0.55, 95% CI 0.34-0.80; P=.002) and artificial ventilation (OR 0.51, 95% CI 0.35-0.75; P<.001) for a patient from vignette 1 without family. In vignette 2, fewer physicians were willing to perform artificial ventilation (OR 0.59, 95% CI 0.39-0.90; P=.02). In vignette 3, significantly fewer physicians showed willingness to perform wound treatment (OR 0.51, 95% CI 0.31-0.84; P=.007), surgery (OR 0.35, 95% CI 0.22-0.57; P<.001), blood transfusion (OR 0.45, 95% CI 0.31-0.66; P<.001), vasopressor (OR 0.49, 95% CI 0.34-0.72; P<.001), dialysis (OR 0.38, 95% CI 0.24-0.59; P<.001), artificial ventilation (OR 0.25, 95% CI 0.15-0.40; P<.001), and chest compression (OR 0.29, 95% CI 0.18-0.47; P<.001) for a patient without family. CONCLUSIONS Elderly patients may have treatments withheld because of the absence of family, highlighting the potential importance of advance care planning in the era of an aging society with a declining birth rate.
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Affiliation(s)
- Kenji Tsuda
- Medical Governance Research Institute, Minatoku, Japan
| | - Asaka Higuchi
- Medical Governance Research Institute, Minatoku, Japan
| | - Emi Yokoyama
- Graduate School of Education, Seisa University, Yokohama, Japan
| | | | | | - Masahiro Kami
- Medical Governance Research Institute, Minatoku, Japan
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15
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Nakamura K, Kinugasa Y, Sugihara S, Hirai M, Yanagihara K, Haruki N, Matsubara K, Kato M, Yamamoto K. Sex differences in surrogate decision-maker preferences for life-sustaining treatments of Japanese patients with heart failure. ESC Heart Fail 2018; 5:1165-1172. [PMID: 30264449 PMCID: PMC6300817 DOI: 10.1002/ehf2.12352] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/16/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS Patients with end-stage heart failure (HF) often require surrogate decision making for end-of-life care owing to a lack of decision-making capacity. However, the clinical characteristics of surrogate decision making for life-sustaining treatments in Japan remain to be investigated. METHODS AND RESULTS Among 934 patients admitted to our hospital for HF from January 2004 to December 2015, we retrospectively reviewed the medical records of consecutive 106 patients who died in hospital (mean age 73 ± 13 years; male, 52.6%). During hospitalization, attending physicians conducted an average of 2.1 ± 1.4 end-of-life conversations with patients and/or their families. Only 4.7% of patients participated in the conversations and declared their preferences; surrogates made medical care decisions in 95.3% of cases. Most decisions by surrogates (98.1%) were made without the patient's advance directive. During initial end-of-life conversations, 49.4% of surrogates requested cardiopulmonary resuscitation (CPR). However, 72.0% of CPR preferences were changed to do not attempt resuscitation (DNAR) orders in the final conversation. Female surrogates were more likely to change the preference from CPR to DNAR than were male surrogates (47.1% vs. 25.0%, P = 0.023). CONCLUSIONS Compared with male surrogates, female surrogates wavered more often in their decisions regarding life-sustaining treatments of Japanese patients with end-stage HF.
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Affiliation(s)
- Kensuke Nakamura
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Yoshiharu Kinugasa
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Shinobu Sugihara
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Masayuki Hirai
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Kiyotaka Yanagihara
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Nobuhiko Haruki
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Koichi Matsubara
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Masahiko Kato
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
| | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, 683-8504, Japan
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