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Lee J, Kim SG, Lee SI, Youn H. Psychosocial Factors Associated With Thoughts Regarding Life-Sustaining Treatment for Oneself and Family Members. Psychiatry Investig 2024; 21:646-654. [PMID: 38960442 PMCID: PMC11222083 DOI: 10.30773/pi.2024.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 07/05/2024] Open
Abstract
OBJECTIVE This study aims to investigate the thoughts of the general population regarding life-sustaining treatment for both oneself and family members and to assess the factors associated with those thoughts. METHODS A total of 1,500 individuals participated in this study by completing a questionnaire consisting of self-reporting items with some instructions, basic demographic information, thoughts on life-sustaining treatment, and psychosocial scales. The disease status was calculated using the Charlson Comorbidity Index. The psychosocial scales included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Pittsburgh Sleep Quality Index, and Multidimensional Scale of Perceived Social Support. RESULTS The majority of participants did not want to receive life-sustaining treatment for both themselves and their families. However, more people wanted life-sustaining treatment for their family members (35.9%) than for themselves (21.6%). Among the basic demographic characteristics, there were significant differences in age, sex, marital status, living arrangements, occupational status, religion, and disease status. Regarding the psychosocial scales, there were significant differences in the PHQ-9 and GAD-7 scores between the group that preferred life-sustaining treatment for family members and the group that did not. CONCLUSION The findings suggest that life-sustaining treatment decisions for oneself and for one's family members can be different. We recommend a more clear expression of one's preferences regarding the last moments of one's life, including advance directives.
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Affiliation(s)
- Jeewon Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Shin-Gyeom Kim
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - HyunChul Youn
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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2
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Mathews J, Merchant S, Galica J, Palmer MJ, O'Donnell J, Koven R, Booth C, Brundage M. Measuring prognostic awareness in patients with advanced cancer: a scoping review and interpretive synthesis of the impact of hope. J Natl Cancer Inst 2024; 116:506-517. [PMID: 38134429 DOI: 10.1093/jnci/djad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Assessment of prognostic awareness (PA) in patients with advanced cancer is challenging because patient responses often indicate their hopes. The objectives of this scoping review were to summarize studies that measured PA in patients with advanced cancer and to synthesize data about how PA was measured and whether hope was incorporated into the measurement. METHODS MEDLINE and Embase databases were searched from inception to December 14, 2021. Data regarding the impact of hope on assessment of PA were extracted when studies reported on patients' beliefs about prognosis and patients' beliefs about their doctor's opinion about prognosis. An interpretive synthesis approach was used to analyze the data and to generate a theory regarding the incorporation of hope into the assessment of PA. RESULTS In total, 52 studies representing 23 766 patients were included. Most were conducted in high-income countries and measured PA based on the goal of treatment (curable vs incurable). Five studies incorporated hope into the assessment of PA and reported that among patients who responded that their treatment goal was a cure, an average of 30% also acknowledged that their doctors were treating them with palliative intent. Interpretive synthesis of the evidence generated a trinary conceptualization of PA patients who are aware and accepting of their prognosis; aware and not accepting; and truly unaware. Each of these groups will benefit from different types of interventions to support their evolving PA. CONCLUSION The trinary conceptualization of PA may promote understanding of the impact of hope in the assessment of PA and guide future research.
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Affiliation(s)
- Jean Mathews
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Shaila Merchant
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
- Division of General Surgery and Surgical Oncology, Queen's University, Kingston, ON, Canada
| | - Jacqueline Galica
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Michael J Palmer
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Jennifer O'Donnell
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Rachel Koven
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Christopher Booth
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Michael Brundage
- Department of Oncology, Queen's University, Kingston, ON, Canada
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3
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Rittberg R, Decker K, Lambert P, Bravo J, St John P, Turner D, Czaykowski P, Dawe DE. Impact of age, comorbidity, and polypharmacy on receipt of systemic therapy in advanced cancers: A retrospective population-based study. J Geriatr Oncol 2024; 15:101689. [PMID: 38219331 DOI: 10.1016/j.jgo.2023.101689] [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: 07/08/2023] [Revised: 11/18/2023] [Accepted: 12/12/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Cancer incidence, comorbidity, and polypharmacy increase with age, but the interplay between these factors on receipt of systemic therapy (ST) in advanced cancer has rarely been studied. MATERIALS AND METHODS A retrospective cohort study was conducted including patients aged ≥18 years diagnosed from 2004 to 2015 with multiple myeloma (MM) (all stages), lung cancer (stage IV), and stage III-IV non-Hodgkin's lymphoma (NHL), breast, colorectal (CRC), prostate, or ovarian cancer in Manitoba, Canada. Clinical and administrative health data were used to determine demographic and cancer characteristics, treatment history, comorbidity (Charlson Comorbidity Index [CCI] and Resource Utilization Band [RUB]), and polypharmacy (≥6 medications). Multivariable logistic regression was used to evaluate variable associations with receipt of ST and interaction with age. RESULTS In total, 17,228 patients were diagnosed with advanced cancer. Ages were distributed as follows: 7% <50 years, 16% 50-59 years, 26% 60-69, 26% 70-79, 24% ≥80 years. ST was administered to 50% of patients. Increased age, polypharmacy, and comorbidity each independently decreased the likelihood of receiving ST. Significant interaction effects were found between age at diagnosis with stage of cancer and cancer type. Differences in probability of ST by cancer stage converged as age increased. In multivariable analysis, adjusting for covariates, patients with MM had the highest odds and lung cancer the lowest odds to receive ST. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age. DISCUSSION Increased age, polypharmacy, and comorbidity were each independently associated with decreased receipt of ST in people with advanced cancers. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age, while age meaningfully interacted with stage and cancer type.
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Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Department of Medical Oncology, BC Cancer, Vancouver, Canada
| | - Kathleen Decker
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Pascal Lambert
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Jen Bravo
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Philip St John
- Section of Geriatric Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - Donna Turner
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Piotr Czaykowski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Canada
| | - David E Dawe
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Canada.
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4
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Barnett MD, Bennett-Leleux LJ, Guillory LA. End-of-life treatment preferences and advanced care planning among older adults. DEATH STUDIES 2024; 48:95-102. [PMID: 36931063 DOI: 10.1080/07481187.2023.2189326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
End-of-life treatment preferences (EOLTPs) refer to the amount of medical intervention an individual would wish to receive in a life-threatening scenario. This study aimed to investigate relationships between older adults' EOLTPs and advance care planning (ACP). Using archival data from two interview surveys of community-dwelling older adults (study 1 n = 331, study 2 n = 338; age 60-102), results found that a desire for less end-of-life medical intervention was associated with greater EOL discussion with physicians. This relationship was explained by greater death preparation and younger age. Older adults may use ACP to limit unwanted medical interventions.
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Affiliation(s)
- Michael D Barnett
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, Texas, USA
| | - Lauren J Bennett-Leleux
- Deparment of Behavioral and Brain Sciences, The University of Texas at Dallas, Dallas, Texas, USA
| | - Logan A Guillory
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, Texas, USA
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5
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Isand KG, Hussain S, Sadiqi M, Kirsimägi Ü, Bond-Smith G, Kolk H, Saar S, Lepner U, Talving P. Frailty Assessment Can Enhance Current Risk Prediction Tools in Emergency Laparotomy: A Retrospective Cohort Study. World J Surg 2023; 47:2688-2697. [PMID: 37589793 DOI: 10.1007/s00268-023-07140-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account. METHODS In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model. RESULTS The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65 years. However, in younger patients, this effect was less marked than in the elderly. CONCLUSION Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals.
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Affiliation(s)
- Karl G Isand
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia.
| | - Shoaib Hussain
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Maseh Sadiqi
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Ülle Kirsimägi
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Giles Bond-Smith
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Helgi Kolk
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Sten Saar
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Peep Talving
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
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Schuijt HJ, Smeeing DPJ, Verberne WR, Groenwold RHH, van Delden JJM, Leenen LPH, van der Velde D. Perspective; recommendations for improved patient participation in decision-making for geriatric patients in acute surgical settings. Injury 2023; 54:110823. [PMID: 37217400 DOI: 10.1016/j.injury.2023.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/24/2023]
Abstract
Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings. When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the "sharedness" of the decision-making process to the needs of the patient and their family.
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Affiliation(s)
- H J Schuijt
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Utrecht University Medical Center, Utrecht, the Netherlands.
| | - D P J Smeeing
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - W R Verberne
- Department of Internal Medicine, Utrecht University Medical Center, Utrecht, the Netherlands
| | - R H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - J J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht, the Netherlands
| | - L P H Leenen
- Department of Surgery, Utrecht University Medical Center, Utrecht, the Netherlands
| | - D van der Velde
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, the Netherlands
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7
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Hallet J, Zuckerman J, Guttman MP, Chesney TR, Haas B, Mahar A, Eskander A, Chan WC, Hsu A, Barabash V, Coburn N. Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis. Ann Surg Oncol 2023; 30:694-708. [PMID: 36068425 DOI: 10.1245/s10434-022-12486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults. PATIENTS AND METHODS We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery. RESULTS Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy. CONCLUSIONS Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.
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Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada. .,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Jesse Zuckerman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Matthew P Guttman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Unity Health, Toronto, ON, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Antoine Eskander
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Wing C Chan
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Amy Hsu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Victoria Barabash
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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8
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Behman R, Chesney T, Coburn N, Haas B, Bubis L, Zuk V, Ashamalla S, Zhao H, Mahar A, Hallet J. Minimally Invasive Compared to Open Colorectal Cancer Resection for Older Adults: A Population-based Analysis of Long-term Functional Outcomes. Ann Surg 2023; 277:291-298. [PMID: 34417359 DOI: 10.1097/sla.0000000000005151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to compare long-term healthcare dependency and time-at-home between older adults undergoing minimally invasive surgery (MIS) for colorectal cancer (CRC) and those undergoing open resection. BACKGROUND Although the benefits of MIS for CRC resection are established, data specific to older adults are lacking. Long-term functional outcomes, central to decision-making in the care for older adults, are unknown. METHODS We performed a population-based analysis of patients ≥70years old undergoing CRC resection between 2007 to 2017 using administrative datasets. Outcomes were receipt of homecare and "high" time-at-home, which we defined as years with ≤14 institution-days, in the 5years after surgery. Homecare was analyzed using time-to-event analyses as a recurrent dichotomous outcome with Andersen-Gill multivariable models. High timeat-home was assessed using Cox multivariable models. RESULTS Of 16,479 included patients with median follow-up of 4.3 (interquartile range 2.1-7.1) years, 7822 had MIS (47.5%). The MIS group had lower homecare use than the open group with 22.3% versus 31.6% at 6 months and 14.8% versus 19.4% at 1 year [hazard ratio 0.87,95% confidence interval (CI) 0.83-0.92]. The MIS group had higher probability ofhigh time-at-home than open surgery with 54.9% (95% CI 53.6%-56.1%) versus 41.2% (95% CI 40.1%-42.3%) at 5years (hazard ratio 0.71, 95% CI 0.68-0.75). CONCLUSIONS Compared to open surgery, MIS for CRC resection was associated with lower homecare needs and higher probability of high time-at-home in the 5 years after surgery, indicating reduced long-term functional dependence. These are important patient-centered endpoints reflecting the overall long-term treatment burden to be taken into consideration in decision-making.
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Affiliation(s)
- Ramy Behman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tyler Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Saint Michael's Hospital - Unity Health, Toronto, Ontario, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada; Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Inter-departmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada; Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Inter-departmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lev Bubis
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Zuk
- Inter-departmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and
| | - Shady Ashamalla
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Haoyu Zhao
- ICES, Toronto, Ontario, Canada; Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada; Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Inter-departmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and
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9
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Hallet J, Tillman B, Zuckerman J, Guttman MP, Chesney T, Mahar AL, Chan WC, Coburn N, Haas B. Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis. J Natl Compr Canc Netw 2022; 20:1223-1232.e9. [PMID: 36351336 DOI: 10.6004/jnccn.2022.7052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults. METHODS Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home. RESULTS Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma). CONCLUSIONS Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.
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Affiliation(s)
- Julie Hallet
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 2Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
| | - Bourke Tillman
- 3ICES, Toronto, Ontario
- 5Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario; and
| | - Jesse Zuckerman
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
| | - Matthew P Guttman
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
| | - Tyler Chesney
- 1Department of Surgery, University of Toronto, Toronto, Ontario
| | - Alyson L Mahar
- 3ICES, Toronto, Ontario
- 6Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Natalie Coburn
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 2Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
| | - Barbara Haas
- 1Department of Surgery, University of Toronto, Toronto, Ontario
- 3ICES, Toronto, Ontario
- 4Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario
- 6Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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10
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Skolarus LE, Lin CC, Kelley AS, Burke JF. National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study. J Pain Symptom Manage 2022; 64:e189-e194. [PMID: 35764201 DOI: 10.1016/j.jpainsymman.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Advance Care Planning is a process of understanding and sharing preferences regarding future medical care. OBJECTIVE To explore individual and national stability of end-of-life treatment preferences among a sample of older adults. METHODS National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8). RESULTS In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios. CONCLUSIONS We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.
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Affiliation(s)
- Lesli E Skolarus
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Chun Chieh Lin
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine (A.S.K.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J Peters VA Medical Center (A.S.K.), Bronx, New York, USA
| | - James F Burke
- Department of Neurology (J.F.B.), Health Services Research Program, Ohio State University, Columbus, Ohio, USA
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11
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Fried TR. Giving up on the objective of providing goal-concordant care: Advance care planning for improving caregiver outcomes. J Am Geriatr Soc 2022; 70:3006-3011. [PMID: 35974460 PMCID: PMC9588724 DOI: 10.1111/jgs.18000] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 01/07/2023]
Abstract
The merits and effectiveness of advance care planning (ACP) continue to be debated a full 30 years after the passage of the Patient Self-Determination Act. This act gave patients the right to create advance directives, with the objective of ensuring that the care they received at the end of life was consistent with their preferences and goals. ACP has definitively moved beyond the completion of advance directives to encompass the identification of a healthcare agent and the facilitation of communication among patients, surrogates, and clinicians. Nonetheless, the provision of goal-concordant care remains a primary objective for ACP. This article argues that this cannot and should not be the objective for ACP. Patients' goals change, and the provision of goal-concordant care is sometimes incompatible with other critical determinants of appropriate care. Instead, ACP should focus on the objective of improving caregiver outcomes. Surrogate decision-making by caregivers is associated with an elevated risk of post-traumatic stress disorder and other adverse outcomes, and these outcomes can be improved with ACP. ACP focused on caregivers involves helping caregivers to understand how they can help to shape the final chapter in a patient's life story, preventing caregivers from making promises they cannot keep, and preparing them to use all relevant information at the time decisions need to be made.
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Affiliation(s)
- Terri R Fried
- Department of Medicine, Yale School of Medicine, and VA Connecticut Healthcare System, New Haven, Connecticut, USA
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12
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Multi-institutional Cohort Study of Elective Diverticulitis Surgery: a National Surgical Quality Improvement Program Database Analysis to Identify Predictors of Non-home Discharge Among Older Adults. J Gastrointest Surg 2022; 26:1899-1908. [PMID: 35524079 DOI: 10.1007/s11605-022-05335-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Older adults often prioritize independence and time spent at home when making major treatment decisions. Identifying preoperative predictors of non-home discharge (i.e., requiring institutional discharge rather than home), among adults undergoing elective diverticulitis surgery, can support surgical decision-making and expectation management. This study aims to (1) examine rates of non-home discharge after elective surgery for diverticulitis and (2) identify predictors of non-home discharge. METHODS This is a multi-institutional cohort study of National Surgical Quality Improvement Program Database. Patients over 18 years who underwent colon resection with diagnosis of diverticulitis were included. Clinical and demographic information were collected by trained nurse reviewers. Emergency operations were excluded. Patients with home versus non-home discharge were compared and predictors identified using multivariable regression. RESULTS Between 2016 and 2019, 40,912 patients were identified. Mean age was 58.5 years (SD = 12.58) with 48.5% 60 + years and 17.7% of patients 70 + years old. The majority (55.9%) were female and "White" race (83.5%). Most patients underwent colectomy without ostomy (88.4%). Nine percent of patients over age 60 had non-home discharge. Functional dependence preoperatively was strongly associated with non-home discharge. On multivariable analysis, significant predictors of non-home discharge were preoperative functional dependence (OR 28.2; 95% CI 9.8-81.7), advancing chronologic age (age 80 + : OR 22.4; 95% CI 18.6-26.9), and preoperative albumin < 3.0 (OR 4.0; 95% CI 3.4-4.6). CONCLUSIONS Nearly one in ten patients over 60 years was not discharged home after elective diverticulitis surgery. Preoperative functional status predicts non-home discharge. Future studies need to assess potentially modifiable causes of non-home discharge, such as social support.
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13
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Blatter R, Amacher SA, Bohren C, Becker C, Beck K, Gross S, Tisljar K, Sutter R, Marsch S, Hunziker S. Comparison of different clinical risk scores to predict long-term survival and neurological outcome in adults after cardiac arrest: results from a prospective cohort study. Ann Intensive Care 2022; 12:77. [PMID: 35978065 PMCID: PMC9385915 DOI: 10.1186/s13613-022-01048-y] [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: 04/13/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Several scoring systems have been used to predict short-term outcome in patients with out-of-hospital cardiac arrest (OHCA), including the disease-specific OHCA and CAHP (Cardiac Arrest Hospital Prognosis) scores, as well as the general severity-of-illness scores Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II). This study aimed to assess the prognostic performance of these four scores to predict long-term outcomes (≥ 2 years) in adult cardiac arrest patients. Methods This is a prospective single-centre cohort study including consecutive cardiac arrest patients admitted to intensive care in a Swiss tertiary academic medical centre. The primary endpoint was 2-year mortality. Secondary endpoints were neurological outcome at 2 years post-arrest assessed by Cerebral Performance Category with CPC 1–2 defined as good and CPC 3–5 as poor neurological outcome, and 6-year mortality. Results In 415 patients admitted to intensive care, the 2-year mortality was 58.1%, with 96.7% of survivors showing good neurological outcome. The 6-year mortality was 82.5%. All four scores showed good discriminatory performance for 2-year mortality, with areas under the receiver operating characteristics curve (AUROC) of 0.82, 0.87, 0.83 and 0.81 for the OHCA, CAHP, APACHE II and SAPS II scores. The results were similar for poor neurological outcome at 2 years and 6-year mortality. Conclusion This study suggests that two established cardiac arrest-specific scores and two severity-of-illness scores provide good prognostic value to predict long-term outcome after cardiac arrest and thus may help in early goals-of-care discussions. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01048-y.
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Affiliation(s)
- René Blatter
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.,Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Chantal Bohren
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.,Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Beck
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland. .,Medical Faculty, University of Basel, Basel, Switzerland.
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14
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Weill SR, Layden AJ, Nabozny MJ, Leahy J, Claxton R, Zelenski AB, Zimmermann C, Childers J, Arnold R, Hall DE. Applying VitalTalk TM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making. JOURNAL OF SURGICAL EDUCATION 2022; 79:983-992. [PMID: 35246401 DOI: 10.1016/j.jsurg.2022.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology. DESIGN A prospective cohort pre-post study; December 2018 to January 2019. SETTING Multi-center tertiary care teaching hospital. PARTICIPANTS Forty-eight resident surgeons from general surgery and otolaryngology. RESULTS Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons. CONCLUSIONS Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalkTM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.
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Affiliation(s)
- Sydney R Weill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Alexander J Layden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Janet Leahy
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Amy B Zelenski
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Julie Childers
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania; The Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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15
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Quinn KL, Krahn M, Stukel TA, Grossman Y, Goldman R, Cram P, Detsky AS, Bell CM. No Time to Waste: An Appraisal of Value at the End of Life. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:S1098-3015(22)01966-0. [PMID: 35690518 DOI: 10.1016/j.jval.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined. METHODS MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life. RESULTS A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed. CONCLUSIONS Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.
| | - Murray Krahn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada
| | - Yona Grossman
- Arts and Science Program, McMaster University, Hamilton, ON, Canada
| | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada; Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
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16
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Perceptions of Patients and Their Families Regarding Limitation of Therapeutic Effort in the Intensive Care Unit. J Clin Med 2021; 10:jcm10214900. [PMID: 34768420 PMCID: PMC8584556 DOI: 10.3390/jcm10214900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/17/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Our objective was to determine and describe the opinion and attitudes of patients and their families regarding the limitation of therapeutic effort and advanced directives in critical patients and whether end-of-life planning occurs. Religious affiliation, education level, and pre-admission quality of life were also evaluated to determine whether they may influence decisions regarding appropriate therapeutic effort. METHODS A prospective, observational and descriptive study, approved by the center's ethical committee, was carried out with 257 participants (94 patients and 163 family members) in the intensive care unit (ICU). A questionnaire regarding the opinions of patients and relatives about situations of therapeutic appropriateness in case of poor prognosis or poor quality of life was used. The questionnaire had three sections. In the first section, sociodemographic features were investigated. In the second section, information was collected on the quality of life and functional situation before ICU admission (taking as a reference the situation one month before admission) assessed by the Karnofsky scale, Barthel index, and the PAEEC scale (Project for the Epidemiological Analysis of Critical Care Patients). The third section aimed to determine whether the family knew the patient's opinion regarding his/her end of life. RESULTS Of those interviewed, 62.2% would agree to limit treatment in case of poor prognosis or poor quality of future life. In contrast, 37.7% considered that they should fight for life, even if it is irretrievable. Only 1.6% had advanced directives registered, 43.9% of the participants admitted deterioration in their quality of life before ICU admission, 18.2% with moderate-severe deterioration. Our study shows that the higher the educational level, the lower the desire to fight for life when it is irretrievable and the greater the agreement to limit treatment. Besides, those participants not affiliated with a religion were significantly less likely to fight for life, including when irretrievable, than Catholics and were more likely to agree to limit treatment. CONCLUSIONS More than half of the participants would agree to limit treatment in the case of a poor prognosis. Our results indicate that patients do not prepare for the dying process well in advance. Religion and educational level were determining factors for the choice of procedures at the end of life, both for patients and their families.
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17
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Deng LX, Tana MM, Lai J. Thinking Ahead: Advance Care Planning for Patients With Cirrhosis. Clin Liver Dis (Hoboken) 2021; 19:7-11. [PMID: 35106142 PMCID: PMC8785911 DOI: 10.1002/cld.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Lisa X. Deng
- Department of MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Michele M. Tana
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCA,Division of Gastroenterology and HepatologyDepartment of MedicineZuckerberg San Francisco General HospitalSan FranciscoCA
| | - Jennifer C. Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California, San FranciscoSan FranciscoCA
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18
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Puthucheary ZA, Osman M, Harvey DJR, McNelly AS. Talking to multi-morbid patients about critical illness: an evolving conversation. Age Ageing 2021; 50:1512-1515. [PMID: 34120162 DOI: 10.1093/ageing/afab107] [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: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Conversations around critical illness outcomes and benefits from intensive care unit (ICU) treatment have begun to shift away from binary discussions on living versus dying. Increasingly, the reality of survival with functional impairment versus survival with a late death is being recognised as relevant to patients. Most ICU admissions are associated with new functional and cognitive disabilities that are significant and long lasting. When discussing outcomes, clinicians rightly focus on patients' wishes and the quality of life (QoL) that they would find acceptable. However, patients' views may encompass differing views on acceptable QoL post-critical illness, not necessarily reflected in standard conversations. Maintaining independence is a greater priority to patients than simple survival. QoL post-critical illness determines judgments on the benefits of ICU support but translating this into clinical practice risks potential conflation of health outcomes and QoL. This article discusses the concept of response shift and the implication for trade-offs between number/length of invasive treatments and change in physical function or death. Conversations need to delineate how health outcomes (e.g. tracheostomy, muscle wasting, etc.) may affect individual outcomes most relevant to the patient and hence impact overall QoL. The research strategy taken to explore decision-making for critically ill patients might benefit from gathering qualitative data, as a complement to quantitative data. Patients, families and doctors are motivated by far wider considerations, and a consultation process should relate to more than the simple likelihood of mortality in a shared decision-making context.
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Affiliation(s)
- Zudin A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - Magda Osman
- School of Biological and Chemical Sciences, Queen Mary University of London, London, UK
| | - Dan J R Harvey
- Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Angela S McNelly
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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19
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Lee KC, Sokas CM, Streid J, Senglaub SS, Coogan K, Walling AM, Cooper Z. Quality Indicators in Surgical Palliative Care: A Systematic Review. J Pain Symptom Manage 2021; 62:545-558. [PMID: 33524478 DOI: 10.1016/j.jpainsymman.2021.01.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/09/2021] [Accepted: 01/19/2021] [Indexed: 02/05/2023]
Abstract
CONTEXT Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. OBJECTIVES To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. METHODS A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. RESULTS There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. CONCLUSION This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.
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Affiliation(s)
- Katherine C Lee
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, California, USA
| | - Claire M Sokas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jocelyn Streid
- Department of Anesthesiology and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven S Senglaub
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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20
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Malhotra C, Koh LE, Teo I, Ozdemir S, Chaudhry I, Finkelstein E. A Prospective Cohort Study of Stability in Preferred Place of Death Among Patients With Stage IV Cancer in Singapore. J Natl Compr Canc Netw 2021; 20:20-28. [PMID: 34359020 DOI: 10.6004/jnccn.2020.7795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves documentation of patients' preferred place of death (PoD). This assumes that patients' preferred PoD will not change over time; yet, evidence for this is inconclusive. We aimed to assess the extent and correlates of change in patients' preferred PoD over time. MATERIALS AND METHODS Using data from a cohort study of patients with advanced cancer in Singapore, we analyzed preferred PoD (home vs institution including hospital, hospice, and nursing home vs unclear) among 466 patients every 6 months for a period of 2 years. At each time point, we assessed the proportion of patients who changed their preferred PoD from the previous time point. Using a multinomial logistic regression model, we assessed patient factors (demographics, understanding of disease stage, ACP, recent hospitalization, quality of life, symptom burden, psychologic distress, financial difficulty, prognosis) associated with change in their preferred PoD. RESULTS More than 25% of patients changed their preferred PoD every 6 months, with no clear trend in change toward home or institution. Patients psychologically distressed at the time of the survey had increased likelihood of changing their preferred PoD to home (relative risk ratio [RRR], 1.02; 95% CI, 1.00-1.05) and to an institution (RRR, 1.06; 95% CI, 1.02-1.10) relative to no change in preference. Patients hospitalized in the past 6 months were more likely to change their preferred PoD to home (RRR, 1.56; 95% CI, 1.07-2.29) and less likely to change to an institution (RRR, 0.50; 95% CI, 0.28-0.88) relative to no change in preference. CONCLUSIONS The present study provides evidence of instability in the preferred PoD of patients with advanced cancer. ACP documents need to be updated regularly to ensure they accurately reflect patients' current preference.
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Affiliation(s)
- Chetna Malhotra
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and
| | - Ling En Koh
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and
| | - Irene Teo
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and.,3Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore
| | - Semra Ozdemir
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and
| | - Isha Chaudhry
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and
| | - Eric Finkelstein
- 1Lien Centre for Palliative Care, and.,2Program in Health Services and Systems Research, Duke-NUS Medical School; and
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Stability of Do-Not-Resuscitate Orders in Hospitalized Adults: A Population-Based Cohort Study. Crit Care Med 2021; 49:240-249. [PMID: 33264125 PMCID: PMC7855253 DOI: 10.1097/ccm.0000000000004726] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Prior work has shown substantial between-hospital variation in do-not-resuscitate orders, but stability of do-not-resuscitate preferences between hospitalizations and the institutional influence on do-not-resuscitate reversals are unclear. We determined the extent of do-not-resuscitate reversals between hospitalizations and the association of the readmission hospital with do-not-resuscitate reversal. DESIGN Retrospective cohort study. SETTING California Patient Discharge Database, 2016-2018. PATIENTS Nonsurgical patients admitted to an acute care hospital with an early do-not-resuscitate order (within 24 hr of admission). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified nonsurgical adult patients who survived an initial hospitalization with an early-do-not-resuscitate order and were readmitted within 30 days. The primary outcome was the association of do-not-resuscitate reversal with readmission to the same or different hospital from the initial hospital. Secondary outcomes included association of readmission to a low versus high do-not-resuscitate-rate hospital with do-not-resuscitate reversal. Among 49,336 patients readmitted within 30 days following a first do-not-resuscitate hospitalization, 22,251 (45.1%) experienced do-not-resuscitate reversal upon readmission. Patients readmitted to a different hospital versus the same hospital were at higher risk of do-not-resuscitate reversal (59.5% vs 38.5%; p < 0.001; adjusted odds ratio = 2.4; 95% CI, 2.3-2.5). Patients readmitted to low versus high do-not-resuscitate-rate hospitals were more likely to have do-not-resuscitate reversals (do-not-resuscitate-rate quartile 1 77.0% vs quartile 4 27.2%; p < 0.001; adjusted odds ratio = 11.9; 95% CI, 10.7-13.2). When readmitted to a different versus the same hospital, patients with do-not-resuscitate reversal had higher rates of mechanical ventilation (adjusted odds ratio = 1.9; 95% CI, 1.6-2.1) and hospital death (adjusted odds ratio = 1.2; 95% CI, 1.1-1.3). CONCLUSIONS Do-not-resuscitate reversals at the time of readmission are more common than previously reported. Although changes in patient preferences may partially explain between-hospital differences, we observed a strong hospital effect contributing to high do-not-resuscitate-reversal rates with significant implications for patient outcomes and resource.
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Lee C, Forner D, Noel CW, Taylor V, MacKay C, Rigby MH, Corsten M, Trites JR, Taylor SM. Functional and Oncologic Outcomes of Octogenarians Undergoing Transoral Laser Microsurgery for Laryngeal Cancer. OTO Open 2021; 5:2473974X211046957. [PMID: 34604690 PMCID: PMC8485289 DOI: 10.1177/2473974x211046957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years. STUDY DESIGN Prospectively collected case series. SETTING QEII Health Sciences Centre, Halifax, Canada. METHODS This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission. RESULTS From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients. CONCLUSION The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes.
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Affiliation(s)
- Changseok Lee
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - David Forner
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Christopher W. Noel
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Victoria Taylor
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Colin MacKay
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Matthew H. Rigby
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Martin Corsten
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - Jonathan R. Trites
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
| | - S. Mark Taylor
- Division of Otolaryngology–Head and Neck Surgery, Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Canada
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23
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Chesney TR, Haas B, Coburn N, Mahar AL, Davis LE, Zuk V, Zhao H, Wright F, Hsu AT, Hallet J. Association of frailty with long-term homecare utilization in older adults following cancer surgery: Retrospective population-based cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:888-895. [PMID: 32980211 DOI: 10.1016/j.ejso.2020.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/09/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Frailty is an important prognostic factor, and the association with postoperative dependence is important outcome to older adults. We examined the association of frailty with long-term homecare utilization for older adults following cancer surgery. METHODS In this population-based cohort study, we determined frailty status in all older adults (≥70 years old) undergoing cancer resection (2007-2017). Outcomes were receipt of homecare and intensity of homecare (days per month) over 5 years. We estimated the adjusted association of frailty with outcomes, and assessed interaction with age. RESULTS Of 82,037 patients, 6443 (7.8%) had frailty. Receipt and intensity of homecare was greater with frailty, but followed similar trajectories over 5 years between groups. Homecare receipt peaked in the first postoperative month (51.4% frailty, 43.1% no frailty), and plateaued by 1 year until 5 years (28.5% frailty, 12.8% no frailty). After 1 year, those with frailty required 4 more homecare days per month than without frailty (14 vs 10 days/month). After adjustment, frailty was associated with increased homecare receipt (hazard ratio 1.40; 95%CI 1.35-1.45), and increasing intensity each year (year 1 incidence rate ratio [IRR] 1.22, 95%CI 1.18-1.27 to year 5 IRR 1.47, 95%CI 1.35-1.59). The magnitude of the association of frailty with homecare receipt decreased with age (pinteraction <0.001). CONCLUSION While the trajectory of homecare receipt and intensity is similar between those with and without frailty, frailty is associated with increased receipt of homecare and increased intensity of homecare after cancer surgery across all age groups.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, St. Michael's Hospital, Toronto, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Frances Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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24
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Wilson JE, Shinall MC, Leath TC, Wang L, Harrell FE, Wilson LD, Nordness MF, Rakhit S, de Riesthal MR, Duff MC, Pandharipande PP, Patel MB. Worse Than Death: Survey of Public Perceptions of Disability Outcomes After Hypothetical Traumatic Brain Injury. Ann Surg 2021; 273:500-506. [PMID: 31972638 PMCID: PMC8558681 DOI: 10.1097/sla.0000000000003389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE). SUMMARY BACKGROUND DATA Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI. METHODS This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from -1 (worse than death) to 1 (full health), with 0 as reference (death). RESULTS Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death. CONCLUSIONS In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.
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Affiliation(s)
- Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of General Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Myrick C. Shinall
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of General Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Taylor C. Leath
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura D. Wilson
- Department of Communication Sciences and Disorders, Oxley College of Health Sciences, The University of Tulsa, Tulsa, OK
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Mina F. Nordness
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Shayan Rakhit
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Michael R. de Riesthal
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa C. Duff
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
- Nashville Veterans Affairs (VA) Medical Center, Geriatric Research Education and Clinical Centers; Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN
| | - Mayur B. Patel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences; Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
- Nashville Veterans Affairs (VA) Medical Center, Geriatric Research Education and Clinical Centers; Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN
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25
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Bilek AJ, Borodin O, Carmi L, Yakim A, Shtern M, Lerman Y. Older patients with active cancer have favorable inpatient rehabilitation outcomes. J Geriatr Oncol 2021; 12:799-807. [PMID: 33358109 DOI: 10.1016/j.jgo.2020.12.010] [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: 07/05/2020] [Revised: 12/06/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To investigate the characteristics and rehabilitation outcomes of older patients with active cancer (OPAC) undergoing post-acute inpatient rehabilitation (IR), and to evaluate which clinical factors are associated with poor rehabilitation outcomes. MATERIALS AND METHODS This is a retrospective study of patients aged ≥65 with active cancer undergoing IR following acute hospitalization at our tertiary hospital centre (N = 330). We collected data on patient, malignancy, and hospitalization characteristics, and IR outcomes including function, mobility, discharge destination, and mortality. Multivariate stepwise logistic regression was used to identify independent associations with the composite outcome of death within three months or discharge to long-term care (LTC). RESULTS Patient mean age was 80.1 ± 7.2 years. The most common malignancies were colon (30.9%) and hematologic (16.1%). Most patients were hospitalized urgently (64.8%) and underwent surgery (72.4%). From IR admission to discharge, patients ambulating independently increased from 14.0% to 52.0%. Discharge destination was to the community (80.4%), to LTC (7.6%), and transfer to an acute ward (7.2%), while 4.8% died during IR. One-year survival was 62.1%. The composite outcome was met by 24.8% of patients with multivariate logistic regression revealing independent associations (p < 0.05) with high baseline dependency, metastatic disease, low mobility score on IR admission, complications during acute care, and ≥ 75th percentile values for lactate dehydrogenase and alkaline phosphatase. CONCLUSION OPAC have favorable IR outcomes including high rate of community discharge, function and mobility gains, and lower mortality rates when compared with previously studied cancer rehabilitation populations. We identified several clinical markers associated with the composite outcome, which can guide post-acute discharge planning in patients with an unclear prognosis.
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Affiliation(s)
- Aaron Jason Bilek
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel.
| | - Oksana Borodin
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel; Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
| | - Liad Carmi
- Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
| | - Ariel Yakim
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel
| | - Michael Shtern
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel
| | - Yaffa Lerman
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel; Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
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26
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Wright FC, Hsu AT, Hallet J. Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment. JAMA Surg 2020; 155:e203754. [PMID: 33026417 DOI: 10.1001/jamasurg.2020.3754] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Functional outcomes are central to cancer care decision-making by older adults. Objective To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure. Design, Setting, and Participants This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018. Main Outcomes and Measures The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used. Results A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time. Conclusions and Relevance This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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Foglia MB, Cohen JH, Batten A, Alfandre D. An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room. J Palliat Med 2020; 24:873-878. [PMID: 33170071 DOI: 10.1089/jpm.2020.0401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Emergency department (ED) visits are common for older patients with chronic, life-limiting illnesses and may offer a valuable opportunity for clinicians to initiate proactive goals of care conversations (GoCC) to ensure end-of-life care that aligns with the patients' values, goals, and preferences. Objectives: The purpose of this study is to assess whether GoCC are occurring with patients in Department of Veteran Affairs (VA) EDs, to characterize these patients' goals of care and life-sustaining treatment (LST) decisions, and to examine the extent to which palliative or hospice consultations occur following the ED visit. Design: We conducted a cross-sectional retrospective study using health record data. Settings/Subjects: A total of 10,780 patients receiving care in VA, whose first GoCC occurred during an ED visit. Results: Of the patients in the study, approximately half were at least 70 years of age, three-quarters were white, and half had multiple serious disease comorbidities. The percentage of patients who desired cardiopulmonary resuscitation was lower among the highest risk (i.e., of hospitalization and death) patients (64% vs. 51%). The percentage of patients wanting other LSTs (e.g., mechanical ventilation) was higher among the lowest risk patients; and the percentage of patients requesting limits to LSTs was highest among higher risk patients. Eighteen percent of patients had a palliative or hospice care consult within three months of their ED visit. Conclusions: In this study, we verified that GoCC are being initiated in the ED with Veterans at differing stages in their illness trajectory and that higher proportions of higher risk patients preferred to limit LSTs.
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Affiliation(s)
- Mary Beth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jennifer H Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Adam Batten
- Seattle Institute for Biomedical and Clinical Research, Seattle, Washington, USA
| | - David Alfandre
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA.,Department of Population Health, New York University School of Medicine, New York, New York, USA
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Hsu AT, Hallet J. Immediate and Long-Term Health Care Support Needs of Older Adults Undergoing Cancer Surgery: A Population-Based Analysis of Postoperative Homecare Utilization. Ann Surg Oncol 2020; 28:1298-1310. [PMID: 32789531 DOI: 10.1245/s10434-020-08992-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA. METHODS This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used. RESULTS Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%). CONCLUSION Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada. .,Sunnybrook Research Institute, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada.
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29
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Rittberg R, Zhang H, Lambert P, Kudlovich R, Kim CA, Dawe DE. Utility of the modified frailty index in predicting toxicity and cancer outcomes for older adults with advanced pancreatic cancer receiving first-line palliative chemotherapy. J Geriatr Oncol 2020; 12:112-117. [PMID: 32798212 DOI: 10.1016/j.jgo.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/25/2020] [Accepted: 07/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cancer primarily affects older adults and is associated with a high morbidity and mortality. Identifying frail patients with advanced pancreatic cancer (APC) helps to mitigate the risks of chemotherapy (CT). The modified Frailty Index (mFI) is an 11-point deficit measure used to identify frail patients. Although validated in surgical fields, it has not been assessed in an APC population. METHODS A retrospective cohort study evaluated consecutive patients, aged ≥65 years, diagnosed with APC from 2011 to 2016 and treated with first line palliative-intent CT. mFI was categorized as: 0, 1, 2 and ≥ 3. Descriptive analysis was completed comparing patient characteristics, CT toxicity, response to treatment, and overall survival (OS) by mFI score. RESULTS 87 patients with APC received palliative CT. Median age was 71 (65-88), 54% male. A mFI score of 0, 1, 2, and ≥ 3 occurred for 20 (23%), 28 (32.2%), 25 (28.7%) and 14 (16.1%) patients respectively. Patients with mFI scores of 0-1 were more likely to receive: 5-fluorouracil, irinotecan and oxaliplatin. CT toxicity, emergency room (ED) and urgent cancer clinic (UCC) presentation, and hospitalization length did not differ by mFI. Longer OS was associated with better ECOG and receipt of combination CT. CONCLUSION This is the first assessment of the mFI in an APC population receiving CT. The mFI score did not correlate with toxicity, ED/UCC visits, hospitalization length or OS. Ongoing assessment of tools that accurately identify frailty in patients with APC is critical to help better select candidates for aggressive CT.
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Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba, 820 Sherbrook St, R3A 1R9 Winnipeg, MB, Canada; CancerCare Manitoba, Department of Hematology and Medical Oncology, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada.
| | - Hanbo Zhang
- Cross Cancer Institute, Department of Oncology, 8440 112 St. NW, T6G 2R7 Edmonton, AB, Canada.
| | - Pascal Lambert
- CancerCare Manitoba, Department of Epidemiology, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada.
| | - Robert Kudlovich
- Department of Internal Medicine, University of Manitoba, 820 Sherbrook St, R3A 1R9 Winnipeg, MB, Canada.
| | - Christina A Kim
- Department of Internal Medicine, University of Manitoba, 820 Sherbrook St, R3A 1R9 Winnipeg, MB, Canada; CancerCare Manitoba, Department of Hematology and Medical Oncology, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada.
| | - David E Dawe
- Department of Internal Medicine, University of Manitoba, 820 Sherbrook St, R3A 1R9 Winnipeg, MB, Canada; CancerCare Manitoba, Department of Hematology and Medical Oncology, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, 675 McDermot Ave, R3E 0V9 Winnipeg, MB, Canada.
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Instability in End-of-Life Care Preference Among Heart Failure Patients: Secondary Analysis of a Randomized Controlled Trial in Singapore. J Gen Intern Med 2020; 35:2010-2016. [PMID: 32103441 PMCID: PMC7351942 DOI: 10.1007/s11606-020-05740-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Efforts to improve quality of end-of-life (EOL) care are increasingly focused on eliciting patients' EOL preference through advance care planning (ACP). However, if patients' EOL preference changes over time and their ACP documents are not updated, these documents may no longer be valid at the time EOL decisions are made. OBJECTIVES To assess extent and correlates of changes in stated preference for aggressive EOL care over time. DESIGN Secondary analysis of data from a randomized controlled trial of a formal ACP program versus usual care in Singapore. PATIENTS Two hundred eighty-two patients with heart failure (HF) and New York Heart Association Classification III and IV symptoms were recruited and interviewed every 4 months for up to 2 years to assess their preference for EOL care. Analytic sample included 200 patients interviewed at least twice. RESULTS Nearly two thirds (64%) of patients changed their preferred type of EOL care at least once. Proportion of patients changing their stated preference for type of EOL care increased with time and the change was not unidirectional. Patients who understood their prognosis correctly were less likely to change their preference from non-aggressive to aggressive EOL care (OR 0.66, p value 0.07) or to prefer aggressive EOL care (OR 0.53; p value 0.001). On the other hand, patient-surrogate discussion of care preference was associated with a higher likelihood of change in patient preference from aggressive to non-aggressive EOL care (OR 1.83; p value 0.03). CONCLUSION The study provides evidence of instability in HF patients' stated EOL care preference. This undermines the value of an ACP document recorded months before EOL decisions are made unless a strategy exists for easily updating this preference. TRIAL REGISTRATION ClinicalTrials.gov: NCT02299180.
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Rubin EB, Buehler A, Halpern SD. Seriously Ill Patients' Willingness to Trade Survival Time to Avoid High Treatment Intensity at the End of Life. JAMA Intern Med 2020; 180:907-909. [PMID: 32250436 PMCID: PMC7136854 DOI: 10.1001/jamainternmed.2020.0681] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This cohort study quantifies trade-offs between survival time and avoidance of intensive care near the end of life among seriously ill hospitalized patients.
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Affiliation(s)
- Emily B Rubin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Anna Buehler
- University of California, San Diego School of Medicine, San Diego
| | - Scott D Halpern
- The Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Huggins M, McGregor MJ, Cox MB, Bauder K, Slater J, Yap C, Mallery L, Moorhouse P, Rusnak C. Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre. Can Geriatr J 2019; 22:182-189. [PMID: 31885758 PMCID: PMC6887142 DOI: 10.5770/cgj.22.377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice. Methods This was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis. Results In 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively. Conclusions Clinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.
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Affiliation(s)
- Madison Huggins
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Margaret J McGregor
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Michelle B Cox
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Katie Bauder
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Jay Slater
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Clarissa Yap
- Home-ViVE Program, Vancouver General Hospital, Vancouver, BC, Canada
| | - Laurie Mallery
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paige Moorhouse
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Conrad Rusnak
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
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Gonzalez AI, Schmucker C, Nothacker J, Motschall E, Nguyen TS, Brueckle MS, Blom J, van den Akker M, Röttger K, Wegwarth O, Hoffmann T, Straus SE, Gerlach FM, Meerpohl JJ, Muth C. Health-related preferences of older patients with multimorbidity: an evidence map. BMJ Open 2019; 9:e034485. [PMID: 31843855 PMCID: PMC6924802 DOI: 10.1136/bmjopen-2019-034485] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence. DESIGN Evidence map (systematic review variant). DATA SOURCES MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018. STUDY SELECTION Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions). DATA EXTRACTION Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software. RESULTS The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies. CONCLUSION Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences. TRIAL REGISTRATION NUMBER Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.
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Affiliation(s)
- Ana Isabel Gonzalez
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Madrid, Spain
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Julia Nothacker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Edith Motschall
- Institute of Medical Biometry and Statistics, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Limburg, Netherlands
| | - Kristian Röttger
- Patient Representative, Federal Joint Committee, Gemeinsamer Bundesausschuss, Berlin, Germany
| | - Odette Wegwarth
- Center for Adaptative Rationality, Max-Planck-Institute for Human Development, Berlin, Germany
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Bond University Faculty of Health Sciences and Medicine, Gold Coast, Queensland, Australia
| | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
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A systematic literature review of the assessment of treatment burden experienced by patients and their caregivers. BMC Geriatr 2019; 19:262. [PMID: 31604424 PMCID: PMC6788093 DOI: 10.1186/s12877-019-1222-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background Many older adults with multiple chronic conditions, particularly those who are functionally impaired, spend considerable time juggling the competing demands of managing their conditions often assisted by caregivers. We examined methods of assessing the treatment burden experienced by this population as a first step to identifying strategies to reduce it. Methods Systematic searches were performed of the peer-reviewed and grey-literature (PubMed, Cochrane library, CINAHL, EMBASE, Web of Science, SCOPUS, New York Academy of Medicine Grey Literature Review, NLM catalog and ProQuest Digital Theses and Dissertations). After title and abstract screening, both qualitative and quantitative articles describing approaches to assessment of treatment burden were included. Results Forty-five articles from the peer reviewed and three items from the grey literature were identified. Most articles (34/48) discussed treatment burden associated with a specific condition. All but one examined the treatment burden experienced by patients and six addressed the treatment burden experienced by caregivers. Qualitative studies revealed many aspects of treatment burden including the burdens of understanding the condition, juggling, monitoring and adjusting treatments, efforts to engage with others for support as well as financial and time burdens. Many tools to assess treatment burden in different populations were identified through the qualitative data. The most commonly used instrument was the Treatment Burden Questionnaire. Conclusions Many instruments are available to assess treatment burden, but no one standardized assessment method was identified. Few articles examined approaches to measuring the treatment burden experienced by caregivers. As people live longer with more chronic conditions healthcare providers need to identify patients and caregivers burdened by treatment and engage in approaches to ameliorate treatment burden. A standard and validated assessment method to measure treatment burden in the clinical setting would help to enhance the care of people with multiple chronic conditions, allow comparison of different approaches to reducing treatment burden, and foster ongoing evaluation and monitoring of burden across conditions, patient populations, and time. Electronic supplementary material The online version of this article (10.1186/s12877-019-1222-z) contains supplementary material, which is available to authorized users.
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Freitas E, Zhang G. Exploration of Patients' Spiritual/Religious Beliefs and Resuscitation Decisions. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2019; 78:216-222. [PMID: 31475249 PMCID: PMC6697654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Artificial resuscitation has potential to reverse a premature death or to prolong the dying process. The resuscitation decision is one of life and death making it imperative that healthcare providers understand patients' beliefs. Making the decision to resuscitate has been associated with patients' spiritual/religious beliefs. Clinicians' assumptions based upon a patients' religion or spiritual beliefs may bias the resuscitation decision. The purpose of this study was to determine associations between hospitalized patients' spiritual/religious beliefs and their resuscitation decisions. A single-site, correlational study was conducted with a convenience sample of hospitalized patients in Honolulu, HI. Patients were enrolled November 2015 to January 2016. Spiritual/religious beliefs were assessed using two validated metrics. Two questions were used to determine the resuscitation decision (chest compressions and intubation). The sample of 84 patients represented no ethnic majority among Caucasian, Asian, and Native Hawaiian/Pacific Islander. Seventy-nine percent of the participants identified theistic spiritual beliefs. No associations were found between resuscitation decisions with either spiritual/religious beliefs or demographic characteristics of this study sample. Interestingly, 20% of the participants answered yes to only one of the resuscitation decision questions. Thus, providers' assumptions should not be made about an association between spiritual/religious beliefs and resuscitation decisions. It is imperative that patients are aware of the necessity for both medical interventions of chest compressions and intubation. Further research should address the complexity of the resuscitation decision, including patients understanding of medical interventions and anticipated prognosis, and other influencing factors.
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Gallo JJ, Abshire M, Hwang S, Nolan MT. Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study. J Pain Symptom Manage 2019; 57:556-565. [PMID: 30576712 PMCID: PMC6382559 DOI: 10.1016/j.jpainsymman.2018.12.328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/07/2018] [Accepted: 12/09/2018] [Indexed: 11/15/2022]
Abstract
CONTEXT Stability of preferences for life-sustaining treatment may vary depending on personal characteristics. OBJECTIVE We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment. DESIGN Mailed survey of older physicians. METHODS Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. Eight hundred ninety eight physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005, and 2011 (mean age 68.2 years at baseline). Preferences for life-sustaining treatment were assessed using a checklist questionnaire in response to a standard "brain injury" scenario and considered as a package using the latent class transition model. RESULTS End-of-life preferences grouped into three classes: most aggressive (wanting most interventions; 14% of physicians), least aggressive (declining most interventions; 61%), and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment, whereas persons with cardiovascular disease and depression had preferences for more aggressive treatment. CONCLUSION Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.
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Affiliation(s)
- Joseph J Gallo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Martha Abshire
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Seungyoung Hwang
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA; American Psychiatric Association, Washington, D.C., USA
| | - Marie T Nolan
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Taylor LJ, Adkins S, Hoel AW, Hauser J, Suwanabol P, Wood G, Anderson W, Branson C, Skube S, Johnson SK, Zelenski A, Tucholka JL, Campbell TC, Schwarze ML. Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication. JOURNAL OF SURGICAL EDUCATION 2019; 76:165-173. [PMID: 30626527 DOI: 10.1016/j.jsurg.2018.05.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/24/2018] [Accepted: 05/27/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity. DESIGN, SETTING, AND PARTICIPANTS We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants. RESULTS Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case. CONCLUSIONS Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.
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Affiliation(s)
- Lauren J Taylor
- Department of Surgery, University of Wisconsin. Madison, Wisconsin
| | - Sarah Adkins
- Department of Medicine. University of California San Francisco. San Francisco, California
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine. Chicago, Illinois
| | - Joshua Hauser
- Department of Medicine, Northwestern University Feinberg School of Medicine. Chicago, Illinois
| | | | - Gordon Wood
- Department of Medicine, Northwestern University Feinberg School of Medicine. Chicago, Illinois
| | - Wendy Anderson
- Department of Medicine. University of California San Francisco. San Francisco, California
| | - Carolina Branson
- Department of Surgery, University of Minnesota. Minneapolis, Minnesota
| | - Steven Skube
- Department of Surgery, University of Minnesota. Minneapolis, Minnesota
| | - Sara K Johnson
- Department of Medicine, University of Wisconsin. Madison, Wisconsin
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin. Madison, Wisconsin
| | | | - Toby C Campbell
- Department of Medicine, University of Wisconsin. Madison, Wisconsin
| | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin. Madison, Wisconsin; Department of Medical History and Bioethics. University of Wisconsin. Madison, Wisconsin.
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Chesney T, Devon K. Training surgical residents to use a framework to promote shared decision-making for patients with poor prognosis experiencing surgical emergencies. Can J Surg 2018; 61:114-120. [PMID: 29582747 DOI: 10.1503/cjs.011317] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Patients with poor underlying prognosis experiencing surgical emergencies face challenging treatment decisions. The Best Case/Worst Case (BC/WC) framework has improved shared decision-making by surgeons, but it is unclear whether residents can be similarly trained. We evaluated senior general surgical residents' acceptance of the BC/WC tool and their attitudes, confidence and actions before and after training. METHODS Two-hour training included a didactic session, live demonstration, small-group practice and debriefing. We developed questionnaires to evaluate residents' attitudes, confidence and actions at 3 time points: before the intervention, after the intervention and 6 months after the intervention. We used the Ottawa Decision Support Framework Acceptability questionnaire to evaluate acceptability and a structured observation form to evaluate performance. RESULTS Eighteen (50%) of 36 invited residents participated. Most residents (83%) felt that a new communication tool would be useful. Almost all (94%) used BC/WC in practice. Residents found the tool acceptable and useful to enhance preference-sensitive communications. They felt that the training was valuable and that role play was its greatest strength but that these situations were challenging to simulate. Barriers to BC/WC use included time constraints and difficulty defining the best and worst cases precisely. Summative attitudes and confidence scores were not different before and after the intervention; however, actions scores were higher after the intervention (p = 0.04). Residents performed a median of 15 (interquartile range 13-17) of the 19 elements on the formative performance evaluation. Commonly missed items were narrating outcomes of palliative approaches, prompting deliberation and providing treatment recommendations. CONCLUSION Senior residents found the BC/WC tool to be acceptable and useful, and are amenable to training in this type of communication. After training, self-reported actions scores increased, and observed performance was accurate.
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Affiliation(s)
- Tyler Chesney
- From the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Chesney, Devon); Women's College Hospital, Toronto, Ont. (Devon); and the Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ont. (Devon)
| | - Karen Devon
- From the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Chesney, Devon); Women's College Hospital, Toronto, Ont. (Devon); and the Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ont. (Devon)
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Kenzik KM, Williams GR, Bhatia S, Balentine CJ. Post-Acute Care among Older Adults with Stage I to III Colorectal Cancer. J Am Geriatr Soc 2018; 67:937-944. [PMID: 30508295 DOI: 10.1111/jgs.15680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little information is available on the long-term use of post-acute care among older patients with colorectal cancer (CRC), relative to individuals without cancer. This study examines the use of post-acute care among older cancer survivors (>65 y) with CRC and compares it with noncancer patients up to 5 years from surgery. DESIGN Retrospective cohort. SETTING SEER-Medicare. PARTICIPANTS Patients treated for stage I to III CRC between January 1, 2000, and December 31, 2011 (n = 40 812) and noncancer Medicare beneficiaries hospitalized for noncancer treatment matching on age, sex, race, comorbidity, and Medicaid dual eligibility. MEASUREMENTS Incident post-acute care claims (skilled nursing, long-term care facility, and home health) from 0 to 100 days, 101 to 365 days, and 1 to 5 years from hospitalization. RESULTS The median age was 77 years. All patients had surgery, 34% received chemotherapy, and 27% received surgery and adjuvant therapy. The cumulative incidence of any post-acute care within 100 days of hospitalization was 45.7% for stage III, 37.9% for stage I/II, and 39% for controls (p < .001). Within the CRC cohort only, the cumulative incidence of post-acute care was 2.9% (stage I/II) and 4.2% (stage III, p < .001) from 101 to 365 days and 15.8% (stage I/II) and 16.9% (stage III, p < .001) from 1 to 5 years. Increasing age, ostomies, and neoadjuvant or adjuvant therapy were associated with increased hazard of all post-acute patients within 100 days from hospitalization. From 1 to 5 years from diagnosis, adjuvant therapy was associated with greater exclusive home health care use. CONCLUSIONS Survivorship planning among older CRC patients should include discussions of post-acute care following cancer therapy, even several years after treatment. J Am Geriatr Soc 67:937-944, 2019.
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Affiliation(s)
- Kelly M Kenzik
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Grant R Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Courtney J Balentine
- Department of Surgery, Dallas VA Hospital & University of Texas Southwestern, Dallas, Texas
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41
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Lee KC, Cooper Z. Ethical considerations about emergent surgical hospitalizations in patients with advanced cancer. Cancer 2018; 124:4432-4434. [PMID: 30427534 DOI: 10.1002/cncr.31684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 06/27/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, University of California, San Diego, La Jolla, California
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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42
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Gross J, Williams B, Fade P, Brett SJ. Intensive care: balancing risk and benefit to facilitate informed decisions. BMJ 2018; 363:k4135. [PMID: 30341067 DOI: 10.1136/bmj.k4135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jamie Gross
- London North West University Healthcare NHS Trust, Watford Road, Harrow HA1 3UJ, UK
| | | | - Premila Fade
- London North West University Healthcare NHS Trust, Watford Road, Harrow HA1 3UJ, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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43
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Tang ST, Wen FH, Chang WC, Hsieh CH, Chou WC, Chen JS, Hou MM. Preferences for Life-Sustaining Treatments Examined by Hidden Markov Modeling Are Mostly Stable in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2017; 54:628-636.e2. [PMID: 28782702 DOI: 10.1016/j.jpainsymman.2017.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Stability of life-sustaining treatment (LST) preferences at end of life (EOL) has not been well established for terminally ill cancer patients nor have transition probabilities been explored between different types of preferences. OBJECTIVE We assessed the stability of cancer patients' LST preferences at EOL by identifying distinct LST preference states and examining the probability of each state transitioning to other states between consecutive time points. METHODS Stability of LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, cardiac massage, intubation with mechanical ventilation, intravenous nutrition support, and nasogastric tube feeding) was examined among 303 cancer patients in their last six months by hidden Markov modeling. RESULTS Six distinct LST preference states (initial size) were identified: uniformly preferring (8.3%), uniformly rejecting (33.8%), and uniformly uncertain about (20.5%) LST, favoring intravenous nutrition support but rejecting other treatments (19.9%), and favoring (3.6%) or uncertain about (14.0%) nutrition support and ICU care while rejecting other treatments. Shifts between LST preference states were relatively small between any two time points (transition probability of staying at the same state was 92.1% to 97.5%), except for the state characterized by uncertainty about nutrition support and ICU care while rejecting other treatments, in which 8.3% of patients shifted LST preferences toward uniform uncertainty at a subsequent assessment. CONCLUSIONS Our patients' LST preferences remained stable without prominent shifts toward preferring less aggressive LSTs even when death approached. Clarifying patients' understanding and expectations about LST efficacy and tailoring interventions to the unique needs of patients in each state may provide personalized EOL care.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
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Vargas N, Tibullo L, Landi E, Carifi G, Pirone A, Pippo A, Alviggi I, Tizzano R, Salsano E, Di Grezia F, Vargas M. Caring for critically ill oldest old patients: a clinical review. Aging Clin Exp Res 2017; 29:833-845. [PMID: 27761759 DOI: 10.1007/s40520-016-0638-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022]
Abstract
Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.
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Affiliation(s)
- Nicola Vargas
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy.
| | - Loredana Tibullo
- Medicine Ward, Medicine Department, "San Giuseppe Moscati" Hospital, via Gramsci, 81031, Aversa, CE, Italy
| | - Emanuela Landi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Giovanni Carifi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Alfonso Pirone
- Clinical Nutrition and Dietology Unit, Medicine Department, Azienda Ospedaliera di Rilievo Nazionale e di alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Antonio Pippo
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Immacolata Alviggi
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Renato Tizzano
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Elisa Salsano
- Department of Clinical Disease and Internal Medicine, Federico II University of Naples, via Pansini, 80121, Naples, Italy
| | - Francesco Di Grezia
- Geriatric and Intensive Geriatric Care Ward, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità "San Giuseppe Moscati", via Contrada Amoretta, 83100, Avellino, Italy
| | - Maria Vargas
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini, 89121, Naples, Italy
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Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg 2017; 152:531-538. [PMID: 28146230 DOI: 10.1001/jamasurg.2016.5674] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, Setting, and Participants Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Interventions A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcomes and Measures We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. Results The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Conclusions and Relevance Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
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Affiliation(s)
| | | | - Nicole M Steffens
- Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado
| | | | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | - Sara K Johnson
- Department of Medicine, University of Wisconsin, Madison
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin, Madison
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | | | | | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin, Madison7Department of Medical History and Bioethics, University of Wisconsin, Madison
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Sudore RL, Boscardin J, Feuz MA, McMahan RD, Katen MT, Barnes DE. Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:1102-1109. [PMID: 28520838 PMCID: PMC5710440 DOI: 10.1001/jamainternmed.2017.1607] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE Documentation rates of patients' medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to planning in busy primary care settings. OBJECTIVE To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation. DESIGN, SETTING, AND PARTICIPANTS This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year. INTERVENTIONS Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements. MAIN OUTCOMES AND MEASURES The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician. RESULTS The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 [95% CI, 1.03-2.51]; P = .04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up). CONCLUSIONS AND RELEVANCE Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01550731.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco
| | - Mariko A Feuz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California
| | - Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California
| | - Mary T Katen
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California
| | - Deborah E Barnes
- San Francisco Veterans Affairs Medical Center, San Francisco, San Francisco, California.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco.,Department of Psychiatry, University of California, San Francisco, San Francisco
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Frey MK, Ellis AE, Koontz LM, Shyne S, Klingenberg B, Fields JC, Chern JY, Blank SV. Ovarian cancer survivors' acceptance of treatment side effects evolves as goals of care change over the cancer continuum. Gynecol Oncol 2017; 146:386-391. [PMID: 28602549 DOI: 10.1016/j.ygyno.2017.05.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/10/2017] [Accepted: 05/24/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Women with ovarian cancer can have long overall survival and goals of treatment change over time from cure to remission to stable disease. We sought to determine whether survivors' acceptance of treatment side effects also changes over the disease continuum. METHODS Women with ovarian cancer completed an online survey focusing on survivors' goals and priorities. The survey was distributed through survivor networks and social media. RESULTS Four hundred and thirty-four women visited the survey website and 328 (76%) completed the survey. Among participants, 141 (43%) identified themselves as having ever recurred, 119 (36%) were undergoing treatment at the time of survey completion and 86 (26%) had received four or more chemotherapy regimens. Respondents' goals of care were cure for 115 women (35%), remission for 156 (48%) and stable disease for 56 (17%). When asked what was most meaningful, 148 women (45%) reported overall survival, 135 (41%) reported quality of life and 40 (12%) reported progression-free survival. >50% of survivors were willing to tolerate the following symptoms for the goal of cure: fatigue (283, 86%), alopecia (281, 86%), diarrhea (232, 71%), constipation (227, 69%), neuropathy (218, 66%), arthralgia (210, 64%), sexual side effects (201, 61%), reflux symptoms (188, 57%), memory loss (180, 55%), nausea/vomiting (180, 55%), hospitalization for treatment side effects (179, 55%) and pain (169, 52%). The rates of tolerance for most symptoms decreased significantly as the goal of treatment changed from cure to remission to stable disease. CONCLUSIONS Women with ovarian cancer willingly accept many treatment side effects when the goal of treatment is cure, however become less accepting when the goal is remission and even less so when the goal is stable disease. Physicians and survivors must carefully consider treatment toxicities and quality of life effects when selecting drugs for patients with incurable disease.
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Affiliation(s)
| | - Annie E Ellis
- Ovarian Cancer Research Fund Alliance (OCRFA), United States; SHARE, United States
| | - Laura M Koontz
- Ovarian Cancer Research Fund Alliance (OCRFA), United States
| | | | | | | | - Jing-Yi Chern
- New York University Langone Medical Center, United States
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Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery. Crit Care Med 2017; 44:1091-7. [PMID: 26841105 DOI: 10.1097/ccm.0000000000001618] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation. DESIGN Retrospective cohort study. SETTING Hospitals throughout the United States. PATIENTS Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized. CONCLUSIONS Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk of mortality and high burdens of treatment. This difficult trajectory should be considered in surgical decision making and has important implications for surgeons, intensivists, and patients.
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Houben CHM, Spruit MA, Schols JMGA, Wouters EFM, Janssen DJA. Response. Chest 2017; 151:1182-1183. [PMID: 28483113 DOI: 10.1016/j.chest.2017.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Martijn A Spruit
- Department of Research and Education, CIRO, Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, the Netherlands
| | - Jos M G A Schols
- Department of Family Medicine and Department of Health Services Research, Faculty of Health, Medicine and Life Sciences/CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Emiel F M Wouters
- Department of Research and Education, CIRO, Horn, the Netherlands; Department of Respiratory Medicine and the Centre of Expertise for Palliative Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Daisy J A Janssen
- Department of Research and Education, CIRO, Horn, the Netherlands; Department of Respiratory Medicine and the Centre of Expertise for Palliative Care, Maastricht UMC+, Maastricht, the Netherlands
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Abstract
ABSTRACTObjective:Advanced care plans (ACPs) are designed to convey the wishes of patients with regards to their care in the event of incapacity. There are a number of prerequisites for creation of an effective ACP. First, the patient must be aware of their condition, their prognosis, the likely trajectory of the illness, and the potential treatment options available to them. Second, patient input into ACP must be free of any coercive factors. Third, the patient must be able to remain involved in adapting their ACP as their condition evolves. Continued use of familial determination and collusion within the local healthcare system, however, has raised concerns that the basic requirements for effective ACP cannot be met.Method:To assess the credibility of these concerns, we employed a video vignette approach depicting a family of three adult children discussing whether or not to reveal a cancer diagnosis to their mother. Semistructured interviews with 72 oncology patients and 60 of their caregivers were conducted afterwards to explore the views of the participants on the different positions taken by the children.Results:Collusion, family-centric decision making, adulteration of information provided to patients, and circumnavigation of patient involvement appear to be context-dependent. Patients and families alike believe that patients should be told of their conditions. However, the incidence of collusion and familial determination increases with determinations of a poor prognosis, a poor anticipated response to chemotherapy, and a poor premorbid health status. Financial considerations with respect to care determinations remain secondary considerations.Significance of results:Our data suggest that ACPs can be effectively constructed in family-centric societies so long as healthcare professionals continue to update and educate families on the patient's situation. Collusion and familial intervention in the decision-making process are part of efforts to protect the patient from distress and are neither solely dependent on cultural nor an “all-or-nothing” phenomenon. The response of families are context-dependent and patient-specific, weighing the patient's right to know and prepare and the potential distress it is likely to cause. In most cases, the news is broken gently over time to allow the patient to digest the information and for the family to assess how well they cope with the news. Furthermore, the actions of families are dependent upon their understanding of the situation, highlighting the need for continued engagement with healthcare professionals.
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