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Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2024; 41:1076-1084. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
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Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
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Sorge J, Szpunar S, Daniel T, Saravolatz L. Using the Electronic Medical Record to Address Code Status Documentation: A Quality Improvement Project. J Healthc Qual 2024; 46:e1-e7. [PMID: 38547078 DOI: 10.1097/jhq.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
ABSTRACT Code status (CS) is often overlooked while admitting patients to the hospital. This is important for patients with end-stage disease. This quality improvement project investigated whether a CS pop-up alert in the electronic medical record, combined with provider education, improved addressing CS. The project consisted of a baseline chart review, implementation of the alert and physician education, and a postintervention chart review. We reviewed 1828 charts at baseline and 1,775 at postintervention. From univariable analysis, there were improvements in addressing CS, being full code, cardiopulmonary resuscitation, intubation, use of vasopressors, and cardioversion technique categories (all p < .001). Documentation of do not resuscitate did not change. From logistic regression, after controlling for age, race, end-stage liver disease, stroke, cancer, hospital unit, and sepsis, patients in the postintervention period were two times more likely to have CS addressed (odds ratio [OR] = 2.04, p < .001). There was a significant improvement in CS documentation from our interventions.
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Sahebi-Fakhrabad A, Kemahlioglu-Ziya E, Handfield R, Wood S, Patel MD, Page CP, Chang L. In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19. Am J Hosp Palliat Care 2023:10499091231222188. [PMID: 38111223 DOI: 10.1177/10499091231222188] [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: 12/20/2023] Open
Abstract
OBJECTIVE The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic. METHODS This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission. RESULTS Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed. CONCLUSION This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.
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Affiliation(s)
| | - Eda Kemahlioglu-Ziya
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Robert Handfield
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Stacy Wood
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cristen P Page
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lydia Chang
- Asheville Pulmonary and Critical Care Associates, Asheville, NC, USA
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Jacobson E, Troost JP, Epler K, Lenhan B, Rodgers L, O'Callaghan T, Painter N, Barrett J. Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study. J Palliat Med 2023; 26:1188-1197. [PMID: 37022771 PMCID: PMC10623069 DOI: 10.1089/jpm.2022.0578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 04/07/2023] Open
Abstract
Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.
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Affiliation(s)
- Emily Jacobson
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Katharine Epler
- Department of Internal Medicine, University of California San Diego, San Diego, California, USA
| | - Blair Lenhan
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lily Rodgers
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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Mallidou AA, Tschanz C, Antifeau E, Lee KY, Mtambo JK, Heckl H. The Medical Orders for Scope of Treatment (MOST) form completion: a retrospective study. BMC Health Serv Res 2022; 22:1186. [PMID: 36131303 PMCID: PMC9492459 DOI: 10.1186/s12913-022-08542-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) involves discussions about patient and families’ wishes and preferences for future healthcare respecting autonomy, improving quality of care, and reducing overtreatment. The Medical Orders for Scope of Treatment (MOST) form records person preferred level and types of treatment and intervention. Purpose To examine the MOST form use in inpatient units within a British Columbia (Canada) hospital, estimate and compare its completion rate, and inform health policies for continuous, quality and individualized patient care. Methods About 5,000 patients admitted to the participating tertiary acute care hospital during October 2020. Data from 780 eligible participants in medical, surgical, or psychiatry unit were analyzed with descriptive statistics, the chi-square test for group comparisons, and logistic regression to assess predictors of the MOST form completion. Results Participants’ (54% men) age ranged from 20–97 years (mean = 59.53, SD = 19.54). Mainly physicians (99.1%) completed the MOST form for about 60% of them. A statistically significant difference of MOST completion found among the units [Pearson χ2(df=2, n=780) = 79.53, p < .001, φ = .319]. Multivariate logistic regression analysis demonstrated that age (OR = 1.05, 95% CI 1.04 to 1.06) and unit admission (OR = .60, 95% CI 0.36 to 0.99 in psychiatry; and OR = .21, 95% CI 0.14 to 0.31 in surgery) were independently associated with the MOST form completion. Conclusion Our findings demonstrate a need for consistent and broad completion of the MOST form across all jurisdictions using, desirably, advanced electronic systems. Healthcare providers need to raise awareness of the MOST completion benefits and be prepared to discuss topics relevant to end-of-life. Further research is required on the MOST form completion.
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Affiliation(s)
- Anastasia A Mallidou
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada.
| | - Coby Tschanz
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
| | - Elisabeth Antifeau
- Palliative Care and End of Life Services, Interior Health, Vancouver, VIC, Canada
| | | | | | - Holly Heckl
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
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Pyles O, Hritz CM, Gulker P, Straveler JD, Grudzen CR, Briggs C, Southerland LT. Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care. J Pain Symptom Manage 2022; 63:e489-e494. [PMID: 34896277 PMCID: PMC9199955 DOI: 10.1016/j.jpainsymman.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR). OBJECTIVES To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit. METHODS Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status. RESULTS Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts). CONCLUSIONS Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.
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Affiliation(s)
- Olivia Pyles
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Christopher M Hritz
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Peg Gulker
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Jansi D Straveler
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Corita R Grudzen
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Cole Briggs
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Lauren T Southerland
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA.
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Day LB, Saunders S, Steinberg L, Ginsburg S, Soong C. "Get the DNR": residents' perceptions of goals of care conversations before and after an e-learning module. CANADIAN MEDICAL EDUCATION JOURNAL 2022; 13:17-28. [PMID: 35291464 PMCID: PMC8909825 DOI: 10.36834/cmej.71956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Residents frequently lead goals of care (GoC) conversations with patients and families to explore patient values and preferences and to establish patient-centered care plans. However, previous work has shown that the hidden curriculum may promote physician-driven agendas and poor communication in these discussions. We previously developed an online learning (e-learning) module that teaches a patient-centered approach to GoC conversations. We sought to explore residents' experiences and how the module might counteract the impact of the hidden curriculum on residents' perceptions and approaches to GoC conversations. METHODS Eleven first-year internal medicine residents from the University of Toronto underwent semi-structured interviews before and after completing the module. Themes were identified using principles of constructivist grounded theory. RESULTS Prior to module completion, residents described institutional and hierarchical pressures to "get the DNR" (Do-Not-Resuscitate), leading to physician-centered GoC conversations focused on code status, documentation, and efficiency. Tensions between formal and hidden curricula led to emotional dissonance and distress. However, after module completion, residents described new patient-centered conceptualizations and approaches to GoC conversations, feeling empowered to challenge physician-driven agendas. This shift was driven by greater alignment of the new approach with their internalized ethical values, greater tolerance of uncertainty and complexity in GoC decisions, and improved clinical encounters in practice. CONCLUSION An e-learning module focused on teaching an evidence-based, patient-centered approach to GoC conversations appeared to promote a shift in residents' perspectives and approaches that may indirectly mitigate the influence of the hidden curriculum, with the potential to improve quality of communication and care.
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Affiliation(s)
| | - Stephanie Saunders
- Department of Rehabilitation Sciences, McMaster University, Ontario, Canada
| | - Leah Steinberg
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Shiphra Ginsburg
- Department of Medicine, University of Toronto, Ontario, Canada
- Wilson Centre for Research in Education, Toronto, Ontario, Canada
| | - Christine Soong
- Department of Medicine, University of Toronto, Ontario, Canada
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8
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Ho S, Kalloniatis M, Ly A. Clinical decision support in primary care for better diagnosis and management of retinal disease. Clin Exp Optom 2022; 105:562-572. [PMID: 35025728 DOI: 10.1080/08164622.2021.2008791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.
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Affiliation(s)
- Sharon Ho
- Centre for Eye Health, The University of New South Wales, Sydney, Australia.,School of Optometry and Vision Science, The University of New South Wales, Sydney, Australia
| | - Michael Kalloniatis
- Centre for Eye Health, The University of New South Wales, Sydney, Australia.,School of Optometry and Vision Science, The University of New South Wales, Sydney, Australia
| | - Angelica Ly
- Centre for Eye Health, The University of New South Wales, Sydney, Australia.,School of Optometry and Vision Science, The University of New South Wales, Sydney, Australia
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Epler K, Lenhan B, O'Callaghan T, Painter N, Troost J, Barrett J, Jacobson E. If Your Heart Were to Stop: Characterization and Comparison of Code Status Orders in Adult Patients Admitted with COVID-19. J Palliat Med 2021; 25:888-896. [PMID: 34967678 DOI: 10.1089/jpm.2021.0486] [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: 11/13/2022] Open
Abstract
Aim: Our aim is to characterize code status documentation for patients hospitalized with novel coronavirus 2019 (COVID-19) during the first peak of the pandemic, when prognosis, resource availability, and provider safety were uncertain. Methods: This retrospective cohort study was performed at a single tertiary academic medical center. Adult patients admitted between March 1, 2020 and October 31, 2020 who tested positive for COVID-19 were included. Demographic and hospital outcome data were collected. Code status orders during this admission and prior admissions were trended. Data were analyzed with multivariable analysis to identify predictors of code status choice. Results: A total of 720 patients were included. The majority (70%) were full code and 12% were in do-not-attempt resuscitation (DNAR) status on admission; by discharge, 20% were DNAR. Age (p < 0.001), time in the intensive care unit (ICU) (p < 0.001), and having Medicaid (p = 0.04) compared to private insurance were predictors of DNAR. Fourteen percent had no code status order. Older age (p < 0.001), time in the ICU (p = 0.01), and admission to a teaching service (p < 0.001) were associated with having an order. Of patients with a prior admission (n = 227), 33.5% previously had no code status order and 44.5% had a different code status for their COVID-19 admission. Of those with a change, most transitioned to less aggressive resuscitation preferences. Conclusions: Most patients hospitalized with COVID-19 in our study elected to be full code. Almost half of patients with prepandemic admissions had a different code status during their COVID-19 admission, with a trend toward less aggressive resuscitation preference.
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Affiliation(s)
- Katharine Epler
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Blair Lenhan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan Troost
- Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Emily Jacobson
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
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10
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Robbins AJ, Ingraham NE, Sheka AC, Pendleton KM, Morris R, Rix A, Vakayil V, Chipman JG, Charles A, Tignanelli CJ. Discordant Cardiopulmonary Resuscitation and Code Status at Death. J Pain Symptom Manage 2021; 61:770-780.e1. [PMID: 32949762 PMCID: PMC8052631 DOI: 10.1016/j.jpainsymman.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status. OBJECTIVES This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors. METHODS The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score). RESULTS A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year. CONCLUSION At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
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Affiliation(s)
- Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adam C Sheka
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexander Rix
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA; Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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11
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Dignam C, Brown M, Thompson CH. Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients. Gerontol Geriatr Med 2021; 7:23337214211003431. [PMID: 33796631 PMCID: PMC7983414 DOI: 10.1177/23337214211003431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.
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Affiliation(s)
- Colette Dignam
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
| | | | - Campbell H Thompson
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
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12
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Erath A, Shipley K, Walker LA, Burrell E, Weavind L. Code status at time of rapid response activation - Impact on escalation of care? Resusc Plus 2021; 6:100102. [PMID: 34223364 PMCID: PMC8244475 DOI: 10.1016/j.resplu.2021.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/23/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background A code status documents the decision to receive or forgo cardiopulmonary resuscitation in the event of cardiac arrest. For patients who undergo a rapid response team activation (RRT) for possible escalation to an intensive care unit (ICU), the presence or absence of a code status represents a critical inflection point for guiding care decisions and resource utilization. This study characterizes the prevalence of code status at the time of RRT and how code status at RRT affects rates of intensive treatments in the ICU. Methods We conducted a single-center retrospective cohort study of 895 rapid response activations occurring over six months. The study included all rapid response team activations for non-obstetric adult inpatients documented in the patient chart. All data was obtained through retrospective chart review. STROBE reporting guidelines were followed. Results At the time of RRT activation, 56% of patients had a documented code status. Code status prevalence was much higher among medical rather than surgical services (74% vs. 13%). For patients escalated to the ICU, having a DNR code status at RRT was not associated with decreased odds of receiving cardioactive medications or advanced respiratory support. Before RRT activation, palliative care utilization was low (9%) but more than doubled after RRT (24% before discharge). Conclusions Barely half of the patients had an active code status at the time of RRT activation. Similar rates of invasive ICU treatments among full code and DNR patients suggest that documented code statuses do not reflect in-depth goals of care discussions, nor does it guide medical teams caring for the patient at times of decompensation.
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Affiliation(s)
- Alexandra Erath
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Kipp Shipley
- Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Erin Burrell
- Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Liza Weavind
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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13
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Escher M, Nendaz M, Scherer F, Cullati S, Perneger T. Physicians' predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study. Palliat Med 2021; 35:161-168. [PMID: 33063607 DOI: 10.1177/0269216320963931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. AIM To determine whether physicians' predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. DESIGN A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. SETTING/PARTICIPANTS ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. RESULTS Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. CONCLUSIONS ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.
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Affiliation(s)
- Monica Escher
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland.,Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Fabienne Scherer
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Cullati
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
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14
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Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial. Crit Care Med 2020; 47:1707-1715. [PMID: 31609772 DOI: 10.1097/ccm.0000000000004016] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients. DESIGN Single-center cluster randomized crossover trial. SETTING Two medical ICUs at Barnes Jewish Hospital. PATIENTS Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality. INTERVENTIONS The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission. MEASUREMENTS AND MAIN RESULTS Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p > 0.05). CONCLUSIONS Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.
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15
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Switzer B, Jazieh K, Bernstein E, Harris D. Impact of an Electronic Medical Record Alert on Code Status Documentation for Hospitalized Patients With Advanced Cancer. JCO Oncol Pract 2020; 16:e257-e263. [DOI: 10.1200/jop.19.00408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Although advance care planning (ACP) in this population improves quality, patient satisfaction, hospice use, rates of harm, and health care costs, ACP documentation rates remain low. We observed changes in ACP documentation by internal medicine residents within a tertiary hospital’s inpatient oncology service after a mandatory training module and enterprise-wide modification in electronic health medical records (EHMR). METHODS: For patients admitted to the Cleveland Clinic oncology service, this 16-week retrospective review observed resident code status (CS) documentation through admission notes and direct EHMR orders before and after implementation of an ACP training module and CS best practice alert (BPA). In addition, residents were surveyed on perceived barriers to CS documentation. RESULTS: In 535 unique admissions (244 before BPA, 291 after BPA), residents exhibited a 14.4% increase (from 47.1% to 61.5%) in admission note CS documentation and an 18.2% increase (from 12.7% to 30.9%) in CS orders at time of discharge. The most common self-reported barrier to ACP documentation was forgetting to discuss, with first-, second-, and third-year residents admitting to feeling uncomfortable in orchestrating ACP conversations at rates of 58%, 6%, and 5%, respectively. CONCLUSION: Resident ACP documentation remains suboptimal in the high-risk cohort of hospitalized patients with advanced cancer. However, rates seem to be positively influenced by online modules and EHMR-based interventions. Additional efforts to improve the current practice and culture of ACP remain a crucial aspect in the quality and safety of our approach to patient care.
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16
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Rubins JB. Use of Combined Do-Not-Resuscitate/Do-Not Intubate Orders Without Documentation of Intubation Preferences: A Retrospective Observational Study at an Academic Level 1 Trauma Center Code Status and Intubation Preferences. Chest 2020; 158:292-297. [PMID: 32109445 DOI: 10.1016/j.chest.2020.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR. RESEARCH QUESTION How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations? METHODS Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization. RESULTS Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation. CONCLUSIONS Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.
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Affiliation(s)
- Jeffrey B Rubins
- University of Minnesota, Division of Palliative Care, Department of Medicine, Hennepin Healthcare, Minneapolis, MN.
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17
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Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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18
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Jain VG, Greco PJ, Kaelber DC. Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic Health Records. Appl Clin Inform 2017; 8:226-234. [PMID: 28271120 DOI: 10.4338/aci-2016-08-ra-0133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 01/06/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Code status (CS) of a patient (part of their end-of-life wishes) can be critical information in healthcare delivery, which can change over time, especially at transitions of care. Although electronic health record (EHR) tools exist for medication reconciliation across transitions of care, much less attention is given to CS, and standard EHR tools have not been implemented for CS reconciliation (CSR). Lack of CSR creates significant potential patient safety and quality of life issues. OBJECTIVE To study the tools, workflow, and impact of clinical decision support (CDS) for CSR. METHODS We established rules for CS implementation in our EHR. At admission, a CS is required as part of a patient's admission order set. Using standard CDS tools in our EHR, we built an interruptive alert for CSR at discharge if a patient did not have the same inpatient (current) CS at discharge as that prior to admission CS. RESULTS Of 80,587 admissions over a four year period (2 years prior to and post CSR implementation), CS discordance was seen in 3.5% of encounters which had full code status prior to admission, but Do Not Resuscitate (DNR) CS at discharge. In addition, 1.4% of the encounters had a different variant of the DNR CS at discharge when compared with CS prior to admission. On pre-post CSR implementation analysis, DNR CS per 1000 admissions per month increased significantly among patients discharged and in patients being admitted (mean ± SD: 85.36 ± 13.69 to 399.85 ± 182.86, p<0.001; and 1.99 ± 1.37 vs 16.70 ± 4.51, p<0.001, respectively). CONCLUSION EHR enabled CSR is effective and represents a significant informatics opportunity to help honor patients' end-of-life wishes. CSR represents one example of non-medication reconciliation at transitions of care that should be considered in all EHRs to improve care quality and patient safety.
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Affiliation(s)
| | | | - David C Kaelber
- David Kaelber, MD, PhD, MPH, 3158 Kingsley Road, Shaker Heights OH 44122,
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19
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Nguyen KL, Alrezk R, Mansourian PG, Naeim A, Rettig MB, Lee CC. The Crossroads of Geriatric Cardiology and Cardio-Oncology. CURRENT GERIATRICS REPORTS 2015; 4:327-337. [PMID: 26543801 PMCID: PMC4624825 DOI: 10.1007/s13670-015-0147-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cancer and cardiovascular disease (CVD) are two major causes of mortality in older adults. With improved survival and outcomes from cancer and CVD, the role of the geriatrician is evolving. Geriatricians provide key skills to facilitate patient-centered and value-based care in the growing older population of cancer patients (and survivors). Cancer treatment in older adults is particularly injurious with respect to complications stemming from cancer therapy and as well as to CVD related to cancer therapy in the context of physiologic aging. To best meet their natural potential as caregiving leaders, geriatricians must hone skills and insights pertaining to oncologic and cardiovascular care, insights that can inform and enhance key management expertise. In this paper, we will review common chemotherapy and radiation-induced cardiovascular complications, screening recommendations, and advance the concept of a geriatric, cardiology, and oncology collaboration. We assert that geriatricians are well suited to a leadership role in the care of older cardio-oncology patients and in the education of primary care physicians and subspecialists on geriatric principles.
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Affiliation(s)
- Kim-Lien Nguyen
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073 USA
| | - Rami Alrezk
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; GRECC, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Pejman G Mansourian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073 USA
| | - Arash Naeim
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Matthew B Rettig
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Cathy C Lee
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA 90073 USA ; Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA USA ; GRECC, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
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20
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Sharma RK, Breu AC. Making progress with code status documentation. J Hosp Med 2015; 10:553-4. [PMID: 25873559 PMCID: PMC4516597 DOI: 10.1002/jhm.2349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/25/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Rashmi K. Sharma
- Division of Hospital Medicine, Northwestern University, Chicago, Illinois
- Address for correspondence and reprint requests: Rashmi K. Sharma, MD, Division of Hospital Medicine, Northwestern University, 211 E. Ontario St., 07-734, Chicago, IL 60611; Telephone: 312-926-0096; Fax: 312-926-4588;
| | - Anthony C. Breu
- Department of Medical Services, VA Boston Healthcare System, West Roxbury, Massachusetts
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