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Adams SY, Redford K, Li R, Malfa A, Tucker R, Lechner BE. Utility of do-not-resuscitate orders for critically ill infants in the NICU. Pediatr Res 2024:10.1038/s41390-024-03367-1. [PMID: 38969816 DOI: 10.1038/s41390-024-03367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/10/2024] [Accepted: 05/07/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To better understand the value of DNR orders for critically ill infants in the NICU. METHODS A prospective mixed-methods approach was utilized including chart review of infants who died in a regional NICU over a twenty-six-month period and surveys of their neonatologists, neonatal fellows, and nurses. RESULTS 40 infants died during the study period and 120 staff surveys were completed. Infants with DNR orders were of a higher gestational age at birth and a higher chronological age at death. Nurses were more likely to perceive benefit from DNR orders than physicians. Medical staff recollection of the existence of DNR orders was not always accurate. Time and fear of adding unnecessary emotional burden to parents were identified as barriers to DNR order implementation. An advanced care planning model built on open communication instead of DNR order documentation was deemed the best approach. CONCLUSION Though DNR orders are beneficial for a subset of infants, DNR orders are likely not applicable for all infants who die in the NICU. More important is supportive, individualized communication between families and the medical team to ensure quality end-of-life care. IMPACT In the adult and pediatric ICU literature, DNR orders are associated with improved qualitative "good death" assessments and decreased familial decision regret. In the NICU, rates of DNR usage aren't well reported and their overall utility is unclear. Though DNR orders can help guide clinical decision making in the NICU and may be associated with higher quality ethical discussion, our data suggest that they are not applicable in all patient cases. We hope that this work will help guide approaches to end-of-life care in the NICU and underscore the importance of frequent, open communication between families and their medical team.
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Affiliation(s)
- Shannon Y Adams
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Katherine Redford
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Randall Li
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ana Malfa
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Richard Tucker
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Beatrice E Lechner
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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2
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Tafazoli A, Cronin-Wood K. Pediatric Oncology Hospice: A Comprehensive Review. Am J Hosp Palliat Care 2024:10499091241227609. [PMID: 38225192 DOI: 10.1177/10499091241227609] [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: 01/17/2024] Open
Abstract
Pediatric hospice is a new terminology in current medical literature. Implementation of pediatric hospice care in oncology setting is a vast but subspecialized field of research and practice. However, it is accompanied by substantial uncertainties, shortages and unexplored sections. The lack of globally established definitions, principles, and guidelines in this field has adversely impacted the quality of end-of-life experiences for children with hospice needs worldwide. To address this gap, we conducted a comprehensive review of scientific literature, extracting and compiling the available but sparse data on pediatric oncology hospice from the PubMed database. Our systematic approach led to development of a well-organized structure introducing the foundational elements, highlighting complications, and uncovering hidden gaps in this critical area. This structured framework comprises nine major categories including general ideology, population specifications, role of parents and family, psychosocial issues, financial complications, service locations, involved specialties, regulations, and quality improvement. This platform can serve as a valuable resource in establishing a scientifically reliable foundation for future experiments and practices in pediatric oncology hospice.
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Affiliation(s)
- Ali Tafazoli
- Healthcare administration program, St Lawrence College, Kingston Campus, ON, Canada
- Hospice Kingston, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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3
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van der Padt‐Pruijsten A, Oostergo T, Leys MBL, van der Rijt CCD, van der Heide A. Hospitalisations of patients with cancer in the last stage of life. Reason to improve advance care planning? Eur J Cancer Care (Engl) 2022; 31:e13720. [PMID: 36172990 PMCID: PMC9788226 DOI: 10.1111/ecc.13720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study is to examine why patients are hospitalised in the last stage of life. METHODS Our study was conducted in a large Dutch teaching hospital. We conducted a retrospective chart review of patients aged ≥18 years who died of cancer either during hospitalisation or after discharge to receive terminal care outside the hospital. We collected data about the characteristics of these hospitalisations and indicators of advance care planning. RESULTS Of the 264 deceased patients, 56% had died in the hospital and 44% after hospital discharge. Of all patients, 80% had been admitted to the hospital because of symptom distress. Dyspnoea (39%) and pain (33%) were the most common symptoms. Most patients underwent diagnostic procedures (laboratory tests [97%] and radiology tests [91%]) and received medical treatment (analgesics [71%] and antibiotics [55%]) during their hospitalisation. A 'Do-Not-Resuscitate' code had been recorded before admission in 42% of the patients and in an additional 52% during admission. CONCLUSION Our study shows that patients with cancer in the last stage of life were mainly admitted to the hospital because of symptom distress. Some hospitalisations and in-hospitals deaths may be avoided by more timely recognition of patients' impending death and start of advance care planning.
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Affiliation(s)
| | - Tanja Oostergo
- Department of Internal MedicineMaasstad HospitalRotterdamThe Netherlands
| | - Maria B. L. Leys
- Department of Internal MedicineMaasstad HospitalRotterdamThe Netherlands
| | - Carin C. D. van der Rijt
- Department Medical OncologyErasmus MC Cancer InstituteRotterdamThe Netherlands,Netherlands Comprehensive Cancer OrganisationThe Netherlands
| | - Agnes van der Heide
- Department of Public HealthErasmus MC, University Medical Centre RotterdamRotterdamThe Netherlands
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4
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Tolppanen AM, Lamminmäki A, Länsimies H, Kataja V, Tyynelä-Korhonen K. Trends in end-of-life decisions among patients dying in a university hospital oncology ward after implantation of a palliative outpatient clinic. Acta Oncol 2022; 61:881-887. [PMID: 35467470 DOI: 10.1080/0284186x.2022.2063068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The need for high quality palliative care at end-of-life has been increasingly recognized while regional differences exist in its quality and availability. Basic palliative care is given by oncologists at any stage of the disease, but this does not cover the high need for specialized palliative care. The aim of this study was to assess the trends in end-of-life decisions among patients dying in a university hospital oncology ward before and after the implementation of a palliative outpatient clinic. MATERIAL AND METHODS The study population consists of all patients who died in the Kuopio University Hospital oncology ward between 1.1.2010-31.10.2011 and 1.1.2012-31.12.2018. The palliative outpatient clinic was established and set up in November - December 2011. Data on inpatient stays, cancer treatments, treatment decisions, and some background factors were retrieved from electronic records. RESULTS The study population totaled 644 patients dying in the oncology ward at KUH (57.8% males; 42.2% females). The deaths comprise 17.2% (191/1108) of all cancer deaths in 2010-2011 and 11.1% (461/4049) in 2012-2018 in the KUH catchment area (North-Savo Health Care District). In years 2012-2018, 14.1% of patients treated at KUH oncology clinic visited the palliative outpatient clinic. The percentage of DNR (do-not-resuscitate), palliative care, and end-of-life (EOL) care decisions increased significantly in the later period. The decisions were mainly made during the last week of life. The proportion of patients receiving chemotherapy during the last two weeks of life remained stable. CONCLUSION The proportion of patients receiving DNR, palliative care and EOL care decisions increased after the implementation of the palliative outpatient clinic, but the decisions were still made rather late, mainly during the last days of life.
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Affiliation(s)
- Anna-Maria Tolppanen
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Annamarja Lamminmäki
- Center of Oncology, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Helena Länsimies
- University of Eastern Finland, Kuopio, Finland
- City of Kuopio, Kuopio, Finland
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5
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Yang CH, Wu CY, Low JTS, Chuang YS, Huang YW, Hwang SJ, Chen PJ. Exploring the Impact of Different Types of Do-Not-Resuscitate Consent on End-of-Life Treatments among Patients with Advanced Kidney Disease: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8194. [PMID: 34360487 PMCID: PMC8346049 DOI: 10.3390/ijerph18158194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
Background: Patients with advanced kidney disease have a symptomatic and psychological burden which warrant renal supportive care or palliative care. However, the impact of do-not-resuscitate consent type (signed by patients or surrogates) on end-of-life treatments in these patients remains unclear. Objective: We aim to identify influential factors correlated with different do-not-resuscitate consent types in patients with advanced kidney disease and the impact of do-not-resuscitate consent types on various life-prolonging treatments. Methods: This was a retrospective observational study. We included patients aged 20 years and over, diagnosed with advanced kidney disease and receiving palliative and hospice care consultation services between January 2014 and December 2018 in a tertiary teaching hospital in Taiwan. We reviewed medical records and used logistic regression to identify factors associated with do-not-resuscitate consent types and end-of-life treatments. Results: A total of 275 patients were included, in which 21% signed their do-not-resuscitate consents. A total of 233 patients were followed until death, and 32% of the decedents continued hemodialysis, 75% underwent nasogastric (NG) tube placement, and 70% took antibiotics in their final seven days of life. Do-not-resuscitate consents signed by patients were associated with reduced life-prolonging treatments including feeding tube placement and antibiotic use in the last seven days (odd ratio and 95% confidence interval were 0.16, 0.07-0.34 and 0.33, 0.16-0.69, respectively) compared to do-not-resuscitate consents signed by surrogates. Conclusions: Do-not-resuscitate consent signed by patients and not by surrogates may reflect better patients' autonomy and reduced life-prolonging treatments in the final seven days of patients with advanced kidney disease.
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Affiliation(s)
- Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Joseph T. S. Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Yu-Wen Huang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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6
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Choudhuri AH, Duggal S, Ahuja B, Uppal R. An Observational Study on the Effects of Delayed Initiation of End-of-Life Care in Terminally ill Young Adults in the Intensive Care Unit. Indian J Palliat Care 2021; 27:31-34. [PMID: 34035614 PMCID: PMC8121244 DOI: 10.4103/ijpc.ijpc_61_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/14/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction The early initiation of end-of-life (EOL) care in terminally ill patients in the intensive care unit (ICU) offers distinct advantages but requires the consent and cooperation of the patients or their relatives. The terminally ill young adults pose distinct set of challenges. The present study was conducted to measure the prevalence and identify and compare the risk factors for the delayed initiation of EOL in terminally ill young adults. Methods The retrospective study was conducted in a mixed medical-surgical 7-bedded ICU after extracting the medical records of all terminally ill young adults in the age group of 20-40 years admitted between June 2014 and November 2018. Only "treatment futile" patients were eligible for inclusion. The patients already on EOL care or with unproven diagnosis were excluded from the study. The commencement of EOL care was divided into (a) normal group (N) and (b) late group (L). The two groups were compared with respect to the demographic factors, outcome, and patient satisfaction level. The factors responsible for the delay were investigated. All statistical analyses were performed using software SPSS 21.0 (SPSS, Inc., Chicago, IL, USA). Results Out of 66 terminally ill young adults with treatment futility, 23 (38.9%) were in the N group and 36 (61.1%) were in the L group (0.8 ± 0.4 days vs. 3.1 ± 1.6 days; P = 0.01). The education level and social and family support of the relatives of the N group were higher (P = 0.03; P - 0.04). The N group had lesser drug consumption of ICU resource usage (14.7% vs. 36.1%, P = 0.01; 18.5% vs. 24.7%, P = 0.04). There was no difference in the duration of mechanical ventilation, ICU stay, and satisfaction level at the time of discharge (or death) from the ICU. Conclusions Our study found a high prevalence of delayed initiation of EOL care in terminally ill young adults and identified the factors responsible for them. The normal initiation of EOL care reduced the usage of medications and resources without affecting the level of patient satisfaction.
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Affiliation(s)
- Anirban Hom Choudhuri
- Department of Anaesthesiology and Intensive Care, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Sakshi Duggal
- Department of Anaesthesiology and Intensive Care, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Bhuvna Ahuja
- Department of Anaesthesiology and Intensive Care, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Rajeev Uppal
- Department of Anaesthesiology and Intensive Care, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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Díez-Manglano J, Sánchez Muñoz LÁ, García Fenoll R, Freire E, Isasi de Isasmendi Pérez S, Carneiro AH, Torres Bonafonte O. Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care. Rev Clin Esp 2021; 221:33-44. [PMID: 32534804 DOI: 10.1016/j.rce.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 01/18/2023]
Abstract
AIM To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when > 95% answers were completely agree or > 90% were agree or completely agree; and weak consensus when > 90% answers were completely agree or > 80% were agree or completely agree. RESULTS The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.
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Affiliation(s)
- J Díez-Manglano
- Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, España.
| | - L Á Sánchez Muñoz
- Servicio de Medicina Interna, Hospital Clínico Universitario, Valladolid, España
| | - R García Fenoll
- Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
| | - E Freire
- Servicio de Medicina Interna, Centro Hospitalar e Universitário do Porto, Portugal
| | | | - A H Carneiro
- Departamento de Medicina, Urgência e UCI, Hospital da Luz Arrábida, Vila Nova de Gaia, Portugal
| | - O Torres Bonafonte
- Servicio de Medicina Interna, Hospital de Sant Pau, Universitat Autònoma de Barcelona, España
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8
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Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care. Rev Clin Esp 2020; 221:33-44. [PMID: 33998477 DOI: 10.1016/j.rceng.2020.04.009] [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: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 11/22/2022]
Abstract
AIM To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when >95% answers were completely agree or >90% were agree or completely agree; and weak consensus when >90% answers were completely agree or >80% were agree or completely agree. RESULTS The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.
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9
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Lee MR, Yu KL, Kuo HY, Liu TH, Ko JC, Tsai JS, Wang JY. Outcome of stage IV cancer patients receiving in-hospital cardiopulmonary resuscitation: a population-based cohort study. Sci Rep 2019; 9:9478. [PMID: 31263137 PMCID: PMC6602946 DOI: 10.1038/s41598-019-45977-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/17/2019] [Indexed: 12/21/2022] Open
Abstract
The effects of cardiopulmonary resuscitation (CPR) on patients with advanced cancer remain to be elucidated. We identified a cohort of patients with stage-IV cancer who received in-hospital CPR from the Taiwan Cancer Registry and National Health Insurance claims database, along with a matched cohort without cancer who also received in-hospital CPR. The main outcomes were post-discharge survival and in-hospital mortality. In total, 3,446 stage-IV cancer patients who underwent in-hospital CPR after cancer diagnosis were identified during January 2009–June 2014. A vast majority of the patients did not survive to discharge (n = 2,854, 82.8%). The median post-discharge survival was 22 days; 10.1% (n = 60; 1.7% of all patients) of the hospital survivors received anticancer therapy after discharge. We created 1:1 age–, sex–, Charlson comorbidity index (CCI)–, and year of CPR–matched noncancer and stage-IV cancer cohorts (n = 3,425 in both; in-hospital mortality rate = 82.1% and 82.8%, respectively). Regression analysis showed that the stage-IV cancer cohort had shorter post-discharge survival than did the noncancer cohort. The outcome of patients with advanced cancer was poor. Even among the survivors, post-discharge survival was short, with only few patients receiving further anticancer therapy.
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Affiliation(s)
- Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kai-Lun Yu
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Yang Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Hao Liu
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Chung Ko
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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10
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Hirvonen OM, Alalahti JE, Syrjänen KJ, Jyrkkiö SM. End-of-life decisions guiding the palliative care of cancer patients visiting emergency department in South Western Finland: a retrospective cohort study. BMC Palliat Care 2018; 17:128. [PMID: 30558583 PMCID: PMC6297980 DOI: 10.1186/s12904-018-0383-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 12/04/2018] [Indexed: 01/21/2023] Open
Abstract
Background Until recently, palliative care (PC) resources in Finland have been sparse. To meet the increasing need for PC an end-of-life (EOL) care project has been ongoing in South Western Finland since 2012, and in 2015, a weekday palliative outpatient clinic was established in Turku University Hospital (TUH). The aim of this study was to explore the effect of the project and the PC clinic on the management practices of EOL cancer patients attending the Emergency Department (ED) of TUH from 2013 to 2016. Methods The medical records of all cancer patients (ICD-10 codes C00–97) admitted to the ED of TUH between August 1–December 31, in 2013 and 2016, were analyzed: n = 529, n = 432 respectively (2013 and 2016). The analysis focused on those patients in EOL care; n = 77, n = 63, respectively. The late palliative patients were defined by PC decision, thus termination of life-prolonging cancer-specific treatments. The EOL patients were in the imminently dying phase of their illness. The site of referral after an ED visit was also verified together with the documentation on advance care plans (ACP), and the impact of palliative outpatient visits. Results In 2016, the number of late palliative and EOL patients admitted to the ED has shown a tendency to decrease. The quality of the documentation for treatment goals, do-not-resuscitate (DNR) orders, living wills and connections to primary care providers has improved since 2013. Prior visits to palliative outpatient clinic correlated well with the more comprehensive ACP information: i) DNR order (p = 0.0001); ii) connection to primary care (p = 0.003); iii) documented ICD-10 code Z51.5 (p = 0.0001). Conclusions Even modest investments in resources for PC can induce an objective change in the allocation of health care resources, and improve the ACP for the cancer patients at their EOL. A visit to a palliative outpatient clinic may offer one approach for improving the quality and completion of ACP documentation.
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Affiliation(s)
- Outi M Hirvonen
- Department of Oncology and Radiotherapy, Turku University Hospital, PO Box 52, FI-20521, Turku, Finland. .,Department of Clinical Oncology, University of Turku, Turku, Finland.
| | - Jenni E Alalahti
- Department of Oncology and Radiotherapy, Turku University Hospital, PO Box 52, FI-20521, Turku, Finland
| | - Kari J Syrjänen
- Department of Clinical Research, Biohit Oyj, Helsinki, Finland
| | - Sirkku M Jyrkkiö
- Department of Oncology and Radiotherapy, Turku University Hospital, PO Box 52, FI-20521, Turku, Finland
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11
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Fu PK, Tung YC, Wang CY, Hwang SF, Lin SP, Hsu CY, Chen DR. Early and late do-not-resuscitate (DNR) decisions in patients with terminal COPD: a retrospective study in the last year of life. Int J Chron Obstruct Pulmon Dis 2018; 13:2447-2454. [PMID: 30147310 PMCID: PMC6097512 DOI: 10.2147/copd.s168049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Purpose The unpredictable trajectory of COPD can present challenges for patients when faced with a decision regarding a do-not-resuscitate (DNR) directive. The current retrospective analysis was conducted to investigate factors associated with an early DNR decision (prior to last hospital admission) and differences in care patterns between patients who made DNR directives early vs late. Patients and methods Electronic health records (EHR) were reviewed from 271 patients with terminal COPD who died in a teaching hospital in Taiwan. Clinical parameters, patterns of DNR decisions, and medical utilization were obtained. Those patients who had a DNR directive earlier than their last (terminal) admission were defined as “Early DNR” (EDNR). Results A total of 234 (86.3%) patients died with a DNR directive, however only 30% were EDNR. EDNR was associated with increased age (OR=1.07; 95% CI: 1.02–1.12), increased ER visits (OR=1.22; 95% CI: 1.10–1.37), rapid decline in lung function (OR=3.42; 95% CI: 1.12–10.48), resting heart rate ≥100 (OR=3.02; 95% CI: 1.07–8.51), and right-sided heart failure (OR=2.38; 95% CI: 1.10–5.19). The median time period from a DNR directive to death was 68.5 days in EDNR patients and 5 days in “Late DNR” (LDNR) patients, respectively (P<0.001). EDNR patients died less frequently in the intensive care unit (P<0.001), received less frequent mechanical ventilation (MV; P<0.001), more frequent non-invasive MV (P=0.006), and had a shorter length of hospital stay (P=0.001). Conclusions Most patients with terminal COPD had DNR directives, however only 30% of DNR decisions were made prior to their last (terminal) hospital admission. Further research using these predictive factors obtained from EHR systems is warranted in order to better understand the relationship between the timing associated with DNR directive decision making in patients with terminal COPD.
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Affiliation(s)
- Pin-Kuei Fu
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.,Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Biotechnology, Hungkuang University, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sheau-Feng Hwang
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan.,Palliative Care Unit, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shin-Pin Lin
- Computer and Communications Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Biostatistics Task Force, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Duan-Rung Chen
- Institute of Health Behaviors and Community Sciences, National Taiwan University, Taipei, Taiwan,
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Huang BY, Chen HP, Wang Y, Deng YT, Yi TW, Jiang Y. The do-not-resuscitate order for terminal cancer patients in mainland China: A retrospective study. Medicine (Baltimore) 2018; 97:e0588. [PMID: 29718859 PMCID: PMC6392573 DOI: 10.1097/md.0000000000010588] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With the development of palliative care, a signed do-not-resuscitate (DNR) order has become increasingly popular worldwide. However, there is no legal guarantee of a signed DNR order for patients with cancer in mainland China. This study aimed to estimate the status of DNR order signing before patient death in the cancer center of a large tertiary affiliated teaching hospital in western China. Patient demographics and disease-related characteristics were also analyzed.This was a retrospective chart analysis. We screened all charts from a large-scale tertiary teaching hospital in China for patients who died of cancer from January 2010 to February 2015. Analysis included a total of 365 records. The details of DNR order forms, patient demographics, and disease-related characteristics were recorded.The DNR order signing rate was 80%. Only 2 patients signed the DNR order themselves, while the majority of DNR orders were signed by patients' surrogates. The median time for signing the DNR order was 1 day before the patients' death. Most DNR decisions were made within the last 3 days before death. The time at which DNR orders were signed was related to disease severity and the rate of disease progression.Our findings indicate that signing a DNR order for patients with terminal cancer has become common in mainland China in recent years. Decisions about a DNR order are usually made by patients' surrogates when patients are severely ill. Palliative care in mainland China still needs to be improved.
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Affiliation(s)
- Bo-Yan Huang
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Hui-Ping Chen
- Department of Palliative Medicine, West China Fourth Hospital, Sichuan University
| | - Ying Wang
- Department of Medical Oncology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, People's Republic of China
| | - Yao-Tiao Deng
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Ting-Wu Yi
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Yu Jiang
- Department of Medical Oncology, Cancer Center, West China Hospital
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