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Doody O, Davidson H, Lombard J. Do not attempt cardiopulmonary resuscitation decision-making process: scoping review. BMJ Support Palliat Care 2024:spcare-2023-004573. [PMID: 38519106 DOI: 10.1136/spcare-2023-004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/23/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVES To conduct a scoping review to explore the evidence of the process of do not attempt cardiopulmonary resuscitation (DNACPR) decision-making. METHODS We conducted a systematic search and review of articles from 1 January 2013 to 6 April 2023 within eight databases. Through multi-disciplinary discussions and content analytical techniques, data were mapped onto a conceptual framework to report the data. RESULTS Search results (n=66 207) were screened by paired reviewers and 58 papers were included in the review. Data were mapped onto concepts/conceptual framework to identify timing of decision-making, evidence of involvement, evidence of discussion, evidence of decision documented, communication and adherence to decision and recommendations from the literature. CONCLUSION The findings provide insights into the barriers and facilitators to DNACPR decision-making, processes and implementation. Barriers arising in DNACPR decision-making related to timing, patient/family input, poor communication, conflicts and ethical uncertainty. Facilitators included ongoing conversation, time to discuss, documentation, flexibility in recording, good communication and a DNACPR policy. Challenges will persist unless substantial changes are made to support and promote examples of good practice. Overall, the review underlined the complexity of DNACPR decision-making and how it is a process shaped by multiple factors including law and policy, resource investment, healthcare professionals, those close to the patient and of central importance, the patient.
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Affiliation(s)
- Owen Doody
- Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Hope Davidson
- School of Law, University of Limerick, Limerick, Ireland
| | - John Lombard
- School of Law, University of Limerick, Limerick, Ireland
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Wang YJ, Hsu CY, Yen AMF, Chen HH, Lai CC. Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department. BMC Palliat Care 2024; 23:51. [PMID: 38389106 PMCID: PMC10885365 DOI: 10.1186/s12904-024-01391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired. METHODS We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year. RESULTS A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic. CONCLUSIONS The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.
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Affiliation(s)
- Yu-Jing Wang
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
- Medical Department, Daichung Hospital, Miaoli, Taiwan
- Taiwan Association of Medical Screening, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan.
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan.
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de Oliveira R, Lobato CB, Maia-Moço L, Santos M, Neves S, Matos MF, Cardoso R, Cruz C, Silva CA, Dias J, Maçães A, Almeida S, Gonçalves AP, Gomes B, Freire E. Palliative medicine in the emergency department: symptom control and aggressive care. BMJ Support Palliat Care 2023; 13:e476-e483. [PMID: 34470770 DOI: 10.1136/bmjspcare-2021-003332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Identifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care. METHODS We conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson's Index. RESULTS 384 adults died at the ED (median age 82 (IQR 72-89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2-4) vs 3 (2-5)), p=0.082. CONCLUSIONS Nearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.
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Affiliation(s)
- Raquel de Oliveira
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Carolina B Lobato
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Endocrine and Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB) & Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal
- Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| | - Leonardo Maia-Moço
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Cancer Biology and Epigenetics Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Mariana Santos
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Sara Neves
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | | | - Rosa Cardoso
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Carla Cruz
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Cátia Araújo Silva
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Joana Dias
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - André Maçães
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Soraia Almeida
- Emergency Department, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
- Infectious Diseases Department, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| | | | - Barbara Gomes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Cicely Saunders Institute of Palliative Care and Rehabilitation, Policy and Rehabilitation, King's College London, London, UK
| | - Elga Freire
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Palliative Care Unit, Department of Internal Medicine, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
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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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The effect of joint involvement of nurse and physician in hospice care on terminal cancer patients on do-not-resuscitate orders signed by surrogates. Palliat Support Care 2022:1-7. [PMID: 35754401 DOI: 10.1017/s147895152200061x] [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: 11/07/2022]
Abstract
OBJECTIVES Patients with terminal cancer often experience physical and mental distress. Signing a do-not-resuscitate order (DNR) is crucial to protect against invalid treatment. This study aims to explore the effect of hospice shared care intervention by medical staff on the completion of a DNR-S (DNR order signed by surrogates) for patients with terminal cancer. METHOD The cross-sectional study in this research involved secondary analysis of data from the 2011-2015 clinical cancer case management database of a medical center in central Taiwan. Those with a DNR order signed by patients (DNR-P) or DNR-S before the hospice shared care consultation were excluded from this study; a total of 1,306 patients with terminal cancer were selected. RESULTS This study demonstrated that the percentage of DNR-S after consultation involving both nurse and physician was 75.4%. With other variables controlled, the number of DNR-Ss after consultation with a nurse was significantly lower [odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.42-0.75] and that of DNR-Ss after consultation involving both nurse and physician was significantly higher (OR = 1.35, 95% CI = 1.01-1.79), than that of DNR-Ss after consultation with only the physician. SIGNIFICANCE OF RESULTS Joint involvement of the nurse and physician in hospice care provides sufficient information to patients and family with terminal cancer about their condition and enhances doctor-patient communication. This effectively assists patients with terminal cancer and their family members in making the major decision of signing a DNR, alleviates the concerns of patients and family members about signing a DNR, and reduces terminal cancer patients' pain at the end of life to ensure that they die in peace and dignity.
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Jiang T, Ma Y, Zheng J, Wang C, Cheng K, Li C, Xu F, Chen Y. Prevalence and related factors of do-not-resuscitate orders among in-hospital cardiac arrest patients. Heart Lung 2021; 51:9-13. [PMID: 34731700 DOI: 10.1016/j.hrtlng.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. MATERIALS AND METHODS We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. RESULTS A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130-1.965), older age (OR 1.016; 95% CI 1.008-1.024), being a local resident (OR 1.790; 95% CI 1.344-2.383), pulmonary infection (OR 1.398; 95% CI 1052-1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009-1.823), shock (OR 1.735; 95% CI 1.301-2.313), acute stroke (OR 1.821; 95% CI 1.235-2.686),neurological dysfunction (OR 1.527; 95% CI 1.149-2.028) and cancer (OR 3.316; 95% CI 2.461-4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419-0.837) were less likely to create DNR orders. CONCLUSION In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.
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Affiliation(s)
- Tangxing Jiang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Yanyan Ma
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chunyi Wang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Kai Cheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chuanbao Li
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
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Ding CQ, Jin JF, Lan MJ, Zhang YP, Wang YW, Yang MF, Wang S. Do-not-resuscitate decision making for terminally ill older patients in the emergency department: An explorative, descriptive inquiry of Chinese family members. Geriatr Nurs 2021; 42:843-849. [PMID: 34090229 DOI: 10.1016/j.gerinurse.2021.04.021] [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: 01/19/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Many terminally ill older adults depend on family members to make medical decisions in China. Many family members find it difficult to make do-not-resuscitate (DNR) decisions in emergency departments (ED). Currently, factors that affect DNR decision making by family members for older adults needing emergency care have not been well studied. This qualitative inquiry explores factors influencing DNR decision-making among family members of terminally ill older adults in ED. Semi-structured in-depth interviews were conducted for a 12-family member of terminally ill older adults at ED in China. Results of the conventional content analysis showed that family members made DNR decisions based on a wide of reasons: (a) subjective perception of family members, (b) conditions of the terminally ill older adults, (c) external environmental factors, and (d) internal family factors. The findings of this study expand our knowledge and understanding of factors influencing DNR decision-making by family members of terminally ill older adults in ED.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang Province, PR China
| | - Jing-Fen Jin
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang Province, PR China.
| | - Mei-Juan Lan
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Yu-Ping Zhang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Yu-Wei Wang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Min-Fei Yang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Sa Wang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
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Huang LJ, Tsai HH, Wang YW, Chou CL. Sailing in a sea of perplexity: Family caregivers' experience of delirium patients. Nurs Crit Care 2021; 27:73-80. [PMID: 33890387 DOI: 10.1111/nicc.12620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/19/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Family caregivers play an important role for patients admitted to the intensive care unit (ICU), and delirium is a common clinical syndrome. Little is known about the experiences of family caregivers when a relative is a patient with delirium, especially for caregivers in Asian cultures. AIMS AND OBJECTIVE To understand the experience of family caregivers with a family member as a patient with delirium in the ICU in Taiwan. DESIGN A descriptive qualitative study with in-depth face-to-face semi-structured interviews. METHODS Interviews were conducted with 20 family caregivers of 20 patients with delirium in the ICU of a hospital in northern Taiwan. RESULTS The core theme describing the phenomenon of family caregivers of a patient with delirium was "Sailing in a sea of perplexity," which described family caregivers' uncertainty of navigating the ICU and providing support for a relative. Three subthemes described the core theme: (a) perplexity of the ICU environment, (b) perplexity of making decisions, and (c) perplexity of Chinese cultural constraints. CONCLUSION "Sailing in a sea of perplexity" underscores how uncertainty among family caregivers of patients with delirium in ICUs can lead to feelings of fear and anxiety. Therefore, nursing professionals should not only focus on patient care but also be sensitive to caregivers' feelings of uncertainty and their cultural beliefs. RELEVANCE TO CLINICAL PRACTICE Unfamiliarity and lack of knowledge about intensive care and patient treatments were a source of family caregivers' perplexity. To reduce uncertainty, we recommend increased communication between staff and caregivers. Hospitals can also provide information on their websites, including treatment of delirium and visitation hours. Information access could be enhanced by developing a smartphone app linked to a QR code that families can scan to obtain information, which would be useful during restricted visitation.
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Affiliation(s)
- Li-Jung Huang
- Department of Medical Intensive Care Unit, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Hsiu-Hsin Tsai
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Yi-Wen Wang
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Liang Chou
- Department of Thoracic Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
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Wang RF, Lai CC, Fu PY, Huang YC, Huang SJ, Chu D, Lin SP, Chaou CH, Hsu CY, Chen HH. A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department. Palliat Med 2021; 35:408-416. [PMID: 33198575 DOI: 10.1177/0269216320972041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM We developed a screening model for predicting 1-year mortality. DESIGN A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.
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Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taipei
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
| | - Ping-Yeh Fu
- Department of Emergency Medicine, Taipei City Hospital, Taipei
| | | | | | - Dachen Chu
- Superintendent, Taipei City Hospital
- National Yang-Ming University, Taipei
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan City
| | - Chen-Yang Hsu
- Master of Public Health Program, College of Public Health, National Taiwan University, Taipei
- Da-Chung Hospital, Miaoli
| | - Hsiu-Hsi Chen
- Division Biostatistics, Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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10
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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11
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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12
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Chen CH, Cheng YH, Chen FJ, Huang EY, Liu PM, Kung CT, Su CH, Chen SH, Chien PC, Hsieh CH. Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study). Risk Manag Healthc Policy 2019; 12:307-315. [PMID: 31849547 PMCID: PMC6911809 DOI: 10.2147/rmhp.s232983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms. Methods Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form. Results The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent. Conclusion This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.
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Affiliation(s)
- Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung 802, Taiwan
| | - Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, 736, Taiwan
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, Kaohsiung 824, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Po-Ming Liu
- Department of Emergency Medicine, Kaohsiung 802, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chao-Hui Su
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Shu-Hwa Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,School of Nursing, Fooyin University, Kaohsiung 831, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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13
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Cheng YH, Chen CH, Chen FJ, Huang EY, Liu PM, Kung CT, Huang HL, Yang LH, Chien PC, Hsieh CH. The training in SHARE communication course by physicians increases the signing of do-not-resuscitate orders for critical patients in the emergency room (cross-sectional study). Int J Surg 2019; 68:20-26. [PMID: 31185311 DOI: 10.1016/j.ijsu.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Communication skills may be an important skill for the front-line emergency physicians. AIM This study aimed to investigate the effect of training in a SHARE communication course by emergency physicians on patient notification and signing of do-not-resuscitate (DNR) orders for critical patients in the emergency room. DESIGN From a total of 29 attending physicians in the emergency department, 19 physicians had been trained in the SHARE communication course. An observation form designed based on the SHARE training was completed by two observers who noted the communication process between physicians and patients and family members during patient notification and signing a DNR order. To assess the influence of physicians trained in a SHARE communication course on the signing of DNR orders, a propensity score-matched population was created to reduce the potential selection bias of patients and family members. SETTING Level 1 trauma medical center in southern Taiwan. RESULTS There were 145 individuals enrolled in the study, of which 93 signed the DNR order, and 52 did not sign it. Analysis from 23 matched pairs from this population revealed that significantly more family members would sign a DNR order if the physician had been trained in the SHARE communication course than when they did not receive this training (78.3% vs. 39.1%, respectively, p = 0.017). The overall score of the observation form for physicians was higher in those individuals who had signed a DNR order than in those who did not sign it (29.48 ± 3.72 vs. 26.13 ± 3.52, respectively, p = 0.003), especially when the physician had chosen a quiet environment (1.35 ± 0.65 vs. 0.87 ± 0.69, respectively, p = 0.020), understood the patient's wishes and confirmed them (1.78 ± 0.42 vs. 1.30 ± 0.70, respectively, p = 0.008), and expressed concern (1.48 ± 0.79 vs. 0.96 ± 0.77, respectively, p = 0.028). In addition, a feedback survey about the feelings experienced by these physicians during the process of patient notification did not reveal a significant difference during the communication with those who had or had not signed DNR orders. CONCLUSION The training in a SHARE communication course can improve the communication skills of emergency physicians in patient notification and signing of DNR orders for critical patients.
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Affiliation(s)
- Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan; Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung, 802, Taiwan.
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, 824, Taiwan.
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Po-Ming Liu
- Department of Emergency Medicine, Yuan's General Hospital, 802, Taiwan.
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Hsien-Li Huang
- Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung, 802, Taiwan; Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Li-Hui Yang
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 833, Taiwan.
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14
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Ganz FD, Sharfi R, Kaufman N, Einav S. Perceptions of slow codes by nurses working on internal medicine wards. Nurs Ethics 2018; 26:1734-1743. [DOI: 10.1177/0969733018783222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Cardio-pulmonary resuscitation is the default procedure during cardio-pulmonary arrest. If a patient does not want cardio-pulmonary resuscitation, then a do not attempt resuscitation order must be documented. Often, this order is not given; even if thought to be appropriate. This situation can lead to a slow code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly. Research objectives: To describe the perceptions of nurses working on internal medicine wards of slow codes, including the factors associated with its implementation. Research design: This was a cross-sectional, descriptive study. Participants completed a personal characteristics questionnaire and the Perceptions and Factors of Slow Codes questionnaire designed for this study. Participants and research context: The sample was a convenience sample of nurses working on internal medicine wards in two Israeli hospitals. Ethical considerations: The study received ethical approval from both institutions, where data were collected and stored according to institutional policy. Findings: Most reported that resuscitations were conducted according to protocol (n = 90, 76.2%). Some took their time calling the code (n = 22, 18.3%), or waited by the bedside and did not perform cardio-pulmonary resuscitation (n = 45, 37.5%). Factors most associated with slow codes were poor patient prognosis (mean = 3.52/5, standard deviation = 1.27) and a low chance of patient survival (mean = 3.37/5, standard deviation = 1.21). Two-thirds (n = 76, 66.8%) reported that slow codes were done on their unit and the majority (n = 80, 69%) perceived slow codes as ethical. Discussion: This study confirms that slow codes are part of medical care on internal medicine wards, where most nurses perceive them as an ethical alternative. These perceptions are in contrast to most legal and ethical opinions expressed in the literature. Conclusion: Nurses should be educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted that further investigate its implementation.
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Affiliation(s)
| | | | | | - Sharon Einav
- Shaare Zedek Medical Centre, Israel; The Hebrew University of Jerusalem, Israel
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15
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Fan JS, Huang HH, Chen YC, How CK, Yen DHT. Emergency department DNR order in patients with spontaneous intracerebral hemorrhage. Am J Emerg Med 2017. [PMID: 28625532 DOI: 10.1016/j.ajem.2017.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH). METHODS Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders. RESULTS Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different. CONCLUSIONS Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.
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Affiliation(s)
- Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chorng-Kuang How
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
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