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Smith-Uffen M, Park J, Parsonson A, Kiely BE, Vasista A. Estimating scenarios for survival time in patients with advanced melanoma receiving immunotherapy and targeted therapy. Oncologist 2024:oyae089. [PMID: 38768122 DOI: 10.1093/oncolo/oyae089] [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: 02/05/2024] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND We aim to provide survival scenario estimates for patients with advanced melanoma starting targeted therapies and immunotherapies. MATERIALS AND METHODS We sought randomized trials of targeted therapies and immunotherapies for advanced melanoma and recorded the following percentiles (represented survival scenario) from each overall survival (OS) curve: 90th (worst-case), 75th (lower-typical), 50th (median), 25th (upper-typical), and 10th (best-case). We tested whether these scenarios can be estimated for each OS curve by multiplying its median by 4 multiples: 0.25 (worst-case), 0.5 (lower-typical), 2 (upper-typical), and 3 (best-case). RESULTS We identified 15 trials with 8025 patients. For first-line combination targeted therapy treatment groups, the median (interquartile range, IQR) in months for each percentile was: 90th, 6.2 (6.0-6.5); 75th, 11.3 (11.3-11.4); and median, 24.4 (23.5-25.3). For the first-line combination immunotherapy treatment group, the percentiles in months were: 90th, 3.9 (2.8-4.5); 75th, 13.4 (10.1-15.4), median 73 (not applicable). In targeted therapy groups, simple multiples of the median OS were accurate for estimating the 90th percentile in 80%; 75th percentile in 40%; 25th percentile in 100%. In immunotherapy groups, these multiples were accurate at 0% for the 90th percentile, and 43% for the 75th percentile. The 90th percentile (worst-case scenario) was better estimated as 1/6× median OS, and the 75th percentile (lower-typical) as 1/3× median OS. CONCLUSIONS Simple multiples of the median OS are a useful framework to estimate scenarios for survival for patients receiving targeted therapies, not immunotherapy. Longer follow-up is required to estimate upper-typical and best-case scenarios.
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Affiliation(s)
| | - John Park
- Department of Medical Oncology, Nepean Cancer Care Centre, Kingswood, NSW, Australia
| | - Andrew Parsonson
- Department of Medical Oncology, Nepean Cancer Care Centre, Kingswood, NSW, Australia
| | - Belinda E Kiely
- NHMRC Clinical trials Centre, University of Sydney, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Anuradha Vasista
- Department of Medical Oncology, Nepean Cancer Care Centre, Kingswood, NSW, Australia
- Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
- The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
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Gross J, Koffman J. Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review. PLoS One 2024; 19:e0299933. [PMID: 38498549 PMCID: PMC10947705 DOI: 10.1371/journal.pone.0299933] [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: 09/12/2023] [Accepted: 02/17/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. AIM To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. DESIGN Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. DATA SOURCES Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. RESULTS Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. CONCLUSIONS Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.
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Affiliation(s)
- Jamie Gross
- Northwick Park and Central Middlesex Hospitals, London North West University Healthcare NHS Trust, Harrow, United Kingdom
- King’s College London, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom
| | - Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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3
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Srinivas S, Villarreal ME, Baselice H, Bergus KC, Waterman B, Henderson K, Scarlet S, Young AJ, Helkin A. Identifying Factors Associated With Code Status Changes After Emergency General Surgery. J Surg Res 2024; 294:150-159. [PMID: 37890274 PMCID: PMC10841616 DOI: 10.1016/j.jss.2023.09.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Surgical emergencies are time sensitive. Identifying patients who may benefit from preoperative goals of care discussions is critical to ensuring that operative intervention aligns with the patient's values. We sought to identify patient factors associated with acute changes in a patient's goals using code status change (CSC) as proxy. METHODS A retrospective analysis of single-institution data for patients undergoing urgent laparotomy was performed. Patients were stratified based on whether a postoperative CSC occurred. Parametric, nonparametric, and regression analyses were used to identify variables associated with CSC. RESULTS Of 484 patients, 13.8% (n = 67) had a postoperative CSC. Patients with postoperative CSC were older (65 versus 60 years, P < 0.001). Odds of CSC were significantly higher in patients who were transferred between facilities (odds ratio [OR] 2.1), had a higher Charlson Comorbidity Index (3-4: OR 3.9, 5+: OR 6.8), and had a higher quick sequential organ failure assessment score (2: OR 5.0; 3: OR 38.7). Patients with anemia (OR 1.9) and active cancer (OR 3.0) had higher odds of CSC. CONCLUSIONS Timely intervention in emergency general surgery may result in high-risk interventions and subsequent complications that do not align with a patient's goals and values. Our analysis identified a subset of patients who undergo surgery and have a postoperative CSC leading to transition to comfort-focused care. In these patients, a pause in clinical momentum may help ensure operative intervention remains goal concordant.
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Affiliation(s)
- Shruthi Srinivas
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Michael E Villarreal
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Holly Baselice
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katherine C Bergus
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brittany Waterman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Sara Scarlet
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew J Young
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alex Helkin
- Department of Trauma and Acute Care Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Sterie AC, Weber O, Jox RJ, Rubli Truchard E. Introducing "A Question That Might, Perhaps, Scare you": How Geriatric Physicians Approach the Discussion About Cardiopulmonary Resuscitation with Hospitalized Patients. HEALTH COMMUNICATION 2023:1-10. [PMID: 37947015 DOI: 10.1080/10410236.2023.2276587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Decisions about the relevance of life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), are commonly made when a patient is admitted to the hospital. This article aims to refine our understanding of how discussions about CPR are introduced, to identify and classify the components frequently occurring in these introductions, and discuss their implications within the overarching activity (discussing CPR). We recorded 43 discussions about CPR between physicians and patients, taking place during the admission interview. We applied an inductive qualitative content analysis and thematic analysis to all the encounter content from the launch of the conversation on CPR to the point at which the physician formulated a question or the patient an answer. We identified this part of the encounter as the "introduction." This systematic method allowed us to code the material, develop and assign themes and subthemes, and quantify it. We identified four major themes in the introductions: (i) agenda setting; (ii) circumstances leading to CPR (subthemes: types of circumstances, personal prognostics of cardiac arrest); (iii) the activity of addressing CPR with the patient (subthemes: routine, constrain, precedence, sensitivity); and (iv) mentioning advance directives. Our findings reveal the elaborate effort that physicians deploy by appealing to combinations of these themes to account for the need to launch conversations about CPR, and highlight how CPR emerges as a sensitive topic.
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Affiliation(s)
- Anca-Cristina Sterie
- Chair of Geriatric Palliative Care, Palliative and Supportive Care Service and Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne
- Service of Palliative and Supportive Care, Lausanne University Hospital and University of Lausanne
| | - Orest Weber
- Liaison Psychiatry Service, Lausanne University Hospital and University of Lausanne
- Department of Language and Information Sciences, Faculty of Arts, University of Lausanne
| | - Ralf J Jox
- Chair of Geriatric Palliative Care, Palliative and Supportive Care Service and Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne
| | - Eve Rubli Truchard
- Chair of Geriatric Palliative Care, Palliative and Supportive Care Service and Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne
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Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2023:10499091231204943. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
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Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
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Comer AR, Fettig L, Bartlett S, Sinha S, D'Cruz L, Odgers A, Waite C, Slaven JE, White R, Schmidt A, Petras L, Torke AM. Code status orders in hospitalized patients with COVID-19. Resusc Plus 2023; 15:100452. [PMID: 37662642 PMCID: PMC10470381 DOI: 10.1016/j.resplu.2023.100452] [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: 03/21/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.
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Affiliation(s)
- Amber R. Comer
- Indiana University School of Health and Human Science, United States
- Indiana University School of Medicine, United States
- American Medical Association, United States
| | - Lyle Fettig
- Indiana University School of Medicine, United States
| | | | - Shilpee Sinha
- Indiana University School of Medicine, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Science, United States
| | - Aubrey Odgers
- Indiana University School of Health and Human Science, United States
| | - Carly Waite
- Indiana University School of Health and Human Science, United States
| | | | - Ryan White
- Indiana University School of Medicine, United States
| | | | - Laura Petras
- Indiana University School of Medicine, United States
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Taylor EP, Vellozzi-Averhoff C, Vettese T. Care Throughout the Journey-The Interaction Between Primary Care and Palliative Care. Clin Geriatr Med 2023; 39:379-393. [PMID: 37385690 DOI: 10.1016/j.cger.2023.04.002] [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] [Indexed: 07/01/2023]
Abstract
Palliative care is no longer synonymous with end-of-life care, and because supply has been well outstripped by demand, much of the practice of palliative care early in a patient's illness journey will take place in the primary care clinic-referred to as primary palliative care. Referral to specialty palliative care for complex symptom management or clarification on decision-making is appropriate, and can facilitate hospice referral, if indicated and in line with patient/family goals.
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Affiliation(s)
- Emily Pinto Taylor
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA; Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Cristina Vellozzi-Averhoff
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Theresa Vettese
- Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Wong SPY, Prince DK, Kurella Tamura M, Hall YN, Butler CR, Engelberg RA, Vig EK, Curtis JR, O’Hare AM. Value Placed on Comfort vs Life Prolongation Among Patients Treated With Maintenance Dialysis. JAMA Intern Med 2023; 183:462-469. [PMID: 36972031 PMCID: PMC10043804 DOI: 10.1001/jamainternmed.2023.0265] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/29/2023] [Indexed: 03/29/2023]
Abstract
Importance Patients receiving maintenance dialysis experience intensive patterns of end-of-life care that might not be consistent with their values. Objective To evaluate the association of patients' health care values with engagement in advance care planning and end-of-life care. Design, Setting, and Participants Survey study of patients who received maintenance dialysis between 2015 and 2018 at dialysis centers in the greater metropolitan areas of Seattle, Washington, and Nashville, Tennessee, with longitudinal follow-up of decedents. Logistic regression models were used to estimate probabilities. Data analysis was conducted between May and October 2022. Exposures A survey question about the value that the participant would place on longevity-focused vs comfort-focused care if they were to become seriously ill. Main Outcomes and Measures Self-reported engagement in advance care planning and care received near the end of life through 2020 using linked kidney registry data and Medicare claims. Results Of 933 patients (mean [SD] age, 62.6 [14.0] years; 525 male patients [56.3%]; 254 [27.2%] identified as Black) who responded to the question about values and could be linked to registry data (65.2% response rate [933 of 1431 eligible patients]), 452 (48.4%) indicated that they would value comfort-focused care, 179 (19.2%) that they would value longevity-focused care, and 302 (32.4%) that they were unsure about the intensity of care they would value. Many had not completed an advance directive (estimated probability, 47.5% [95% CI, 42.9%-52.1%] of those who would value comfort-focused care vs 28.1% [95% CI, 24.0%-32.3%] of those who would value longevity-focused care or were unsure; P < .001), had not discussed hospice (estimated probability, 28.6% [95% CI, 24.6%-32.9%] comfort focused vs 18.2% [95% CI, 14.7%-21.7%] longevity focused or unsure; P < .001), or had not discussed stopping dialysis (estimated probability, 33.3% [95% CI, 29.0%-37.7%] comfort focused vs 21.9% [95% CI, 18.2%-25.8%] longevity focused or unsure; P < .001). Most respondents wanted to receive cardiopulmonary resuscitation (estimated probability, 78.0% [95% CI, 74.2%-81.7%] comfort focused vs 93.9% [95% CI, 91.4%-96.1%] longevity focused or unsure; P < .001) and mechanical ventilation (estimated probability, 52.0% [95% CI, 47.4%-56.6%] comfort focused vs 77.9% [95% CI, 74.0%-81.7%] longevity focused or unsure; P < .001). Among decedents, the percentages of participants who received an intensive procedure during the final month of life (estimated probability, 23.5% [95% CI, 16.5%-31.0%] comfort focused vs 26.1% [95% CI, 18.0%-34.5%] longevity focused or unsure; P = .64), discontinued dialysis (estimated probability, 38.3% [95% CI, 32.0%-44.8%] comfort focused vs 30.2% [95% CI, 23.0%-37.8%] longevity focused or unsure; P = .09), and enrolled in hospice (estimated probability, 32.2% [95% CI, 25.7%-38.7%] comfort focused vs 23.3% [95% CI, 16.4%-30.5%] longevity focused or unsure; P = .07) were not statistically different. Conclusions and Relevance This survey study found that there appeared to be a disconnect between patients' expressed values, which were largely comfort focused, and their engagement in advance care planning and end-of-life care, which reflected a focus on longevity. These findings suggest important opportunities to improve the quality of care for patients receiving dialysis.
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Affiliation(s)
| | | | | | - Yoshio N. Hall
- Department of Medicine, University of Washington, Seattle
| | | | | | | | - J. Randall Curtis
- Department of Medicine, Stanford University, Palo Alto, California
- Cambia Palliative Care Center of Excellence, Department of Medicine, University of Washington, Seattle
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
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10
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Sterie AC, Castillo C, Jox RJ, Büla CJ, Rubli Truchard E. "If I Become a Vegetable, Then no": A Thematic Analysis of How Patients and Physicians Refer to Prognosis When Discussing Cardiopulmonary Resuscitation. Gerontol Geriatr Med 2023; 9:23337214231208824. [PMID: 37954661 PMCID: PMC10634265 DOI: 10.1177/23337214231208824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 11/14/2023] Open
Abstract
Background: Documenting decisions about the relevance cardiopulmonary resuscitation (CPR) is a standard practice at hospital admission yet a complex task. Objective: Our aim was to explore how physicians approach and discuss CPR prognosis with older patients recently admitted to a post-acute care unit. Method: We recorded 43 conversations between physicians and patients about the relevancy of CPR that took place at admission at the geriatric rehabilitation service of a Swiss university hospital. Thematic analysis determined (i) who initiated the talk about CPR prognosis, (ii) at what point in the conversation, and (iii) how prognosis was referred to. Results: Prognosis was mentioned in 65% of the conversations. We categorized the content of references to CPR prognosis in five themes: factors determining the prognosis (general health, age, duration of maneuvers); life (association of CPR with life, survival); proximal adverse outcomes (broken ribs, intensive care); long-term adverse outcomes (loss of autonomy, suffering a stroke, pain, generic, uncertainty); and being a burden. Discussion and conclusion: Discussing CPR is important to all patients, including those for whom it is not recommended. Information about CPR prognosis is essential to empower and support patients in expressing their expectations from life-prolonging interventions and attain shared decision-making.
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Affiliation(s)
| | - Clara Castillo
- Lausanne University Hospital and Lausanne University, Switzerland
| | - Ralf J. Jox
- Lausanne University Hospital and Lausanne University, Switzerland
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Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Lee RS, Santangelo I, Hasdianda MA, Wang W, George N, Liu SW, Kennedy M, Schonberg MA, Block SD, Tulsky JA, Ouchi K. Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians. J Pain Symptom Manage 2023; 65:58-65. [PMID: 36265695 PMCID: PMC9790029 DOI: 10.1016/j.jpainsymman.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training. OBJECTIVES To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training. METHODS A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals. RESULTS Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups. CONCLUSION Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (T.P.), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Emily L Aaronson
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Palliative Care and Geriatric Medicine (M.H.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel S Lee
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammad A Hasdianda
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA
| | - Wei Wang
- Department of Medicine and Neurology, Brigham and Women's Hospital (W.W.), Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine `(N.G.), Division of Critical Care, University of New Mexico, Albuquerque, New Mexico, USA
| | - Shan W Liu
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mara A Schonberg
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Medicine (M.A.S.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Susan D Block
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Tulsky
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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DeMario BS, Stanley SP, Truong EI, Ladhani HA, Brown LR, Ho VP, Kelly ML. Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study. Neurosurgery 2022; 91:e45-e50. [PMID: 35471648 PMCID: PMC9514740 DOI: 10.1227/neu.0000000000002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/05/2022] [Indexed: 12/21/2022] Open
Abstract
Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.
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Affiliation(s)
| | - Samuel P. Stanley
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Husayn A. Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
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13
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Zhu Y, Enguidanos S. Advance directives completion and hospital out-of-pocket expenditures. J Hosp Med 2022; 17:437-444. [PMID: 35527477 PMCID: PMC9325451 DOI: 10.1002/jhm.12839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-of-pocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life. METHODS We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage. RESULTS About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average). CONCLUSIONS AD completion was significantly associated with lower hospital out-of-pocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.
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Affiliation(s)
- Yujun Zhu
- Leonard Davis School of GerontologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Susan Enguidanos
- Leonard Davis School of GerontologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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14
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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15
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Sabouneh R, Lakissian Z, Hilal N, Sharara-Chami R. The State of the Do-Not-Resuscitate Order in a Pediatric Intensive Care Unit in the Middle East: A Retrospective Study. J Palliat Care 2022; 37:99-106. [PMID: 35014894 DOI: 10.1177/08258597211073228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Do-Not-Resuscitate (DNR) order is part of most hospitals' policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. METHODS This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. RESULTS Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested "soft" resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. CONCLUSIONS The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for "soft" resuscitations like administering epinephrine without chest compressions.
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Affiliation(s)
- R Sabouneh
- American University of Beirut Medical Centre (AUBMC)
| | - Z Lakissian
- Dar Al-Wafaa Simulation in Medicine (DAWSIM), AUBMC
| | - N Hilal
- American University of Beirut Medical Centre (AUBMC)
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16
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Epler K, Lenhan B, O'Callaghan T, Painter N, Troost J, Barrett J, Jacobson E. If Your Heart Were to Stop: Characterization and Comparison of Code Status Orders in Adult Patients Admitted with COVID-19. J Palliat Med 2021; 25:888-896. [PMID: 34967678 DOI: 10.1089/jpm.2021.0486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aim: Our aim is to characterize code status documentation for patients hospitalized with novel coronavirus 2019 (COVID-19) during the first peak of the pandemic, when prognosis, resource availability, and provider safety were uncertain. Methods: This retrospective cohort study was performed at a single tertiary academic medical center. Adult patients admitted between March 1, 2020 and October 31, 2020 who tested positive for COVID-19 were included. Demographic and hospital outcome data were collected. Code status orders during this admission and prior admissions were trended. Data were analyzed with multivariable analysis to identify predictors of code status choice. Results: A total of 720 patients were included. The majority (70%) were full code and 12% were in do-not-attempt resuscitation (DNAR) status on admission; by discharge, 20% were DNAR. Age (p < 0.001), time in the intensive care unit (ICU) (p < 0.001), and having Medicaid (p = 0.04) compared to private insurance were predictors of DNAR. Fourteen percent had no code status order. Older age (p < 0.001), time in the ICU (p = 0.01), and admission to a teaching service (p < 0.001) were associated with having an order. Of patients with a prior admission (n = 227), 33.5% previously had no code status order and 44.5% had a different code status for their COVID-19 admission. Of those with a change, most transitioned to less aggressive resuscitation preferences. Conclusions: Most patients hospitalized with COVID-19 in our study elected to be full code. Almost half of patients with prepandemic admissions had a different code status during their COVID-19 admission, with a trend toward less aggressive resuscitation preference.
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Affiliation(s)
- Katharine Epler
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Blair Lenhan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan Troost
- Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Emily Jacobson
- Department of Internal Medicine, Department of Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
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Swamy L, Cooper AZ. Did You Confirm Code Status?: Code Status Discussions as a Checkbox on Hospital Admission. Chest 2021; 160:2335-2337. [PMID: 34872671 DOI: 10.1016/j.chest.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/15/2021] [Accepted: 08/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lakshmana Swamy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Cambridge Health Alliance, Cambridge, MA
| | - Avraham Z Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
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18
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Sterie A, Jones L, Jox RJ, Truchard ER. 'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions. Health Expect 2021; 24:790-799. [PMID: 33682993 PMCID: PMC8235896 DOI: 10.1111/hex.13212] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. OBJECTIVE The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. METHOD We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. RESULTS Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. DISCUSSION AND CONCLUSIONS The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care. PATIENT CONTRIBUTION Patients were involved in the data collection stage of the study.
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Affiliation(s)
- Anca‐Cristina Sterie
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Laura Jones
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Ralf J. Jox
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Institute of Humanities in MedicineLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Eve Rubli Truchard
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
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19
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Erath A, Shipley K, Walker LA, Burrell E, Weavind L. Code status at time of rapid response activation - Impact on escalation of care? Resusc Plus 2021; 6:100102. [PMID: 34223364 PMCID: PMC8244475 DOI: 10.1016/j.resplu.2021.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/23/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background A code status documents the decision to receive or forgo cardiopulmonary resuscitation in the event of cardiac arrest. For patients who undergo a rapid response team activation (RRT) for possible escalation to an intensive care unit (ICU), the presence or absence of a code status represents a critical inflection point for guiding care decisions and resource utilization. This study characterizes the prevalence of code status at the time of RRT and how code status at RRT affects rates of intensive treatments in the ICU. Methods We conducted a single-center retrospective cohort study of 895 rapid response activations occurring over six months. The study included all rapid response team activations for non-obstetric adult inpatients documented in the patient chart. All data was obtained through retrospective chart review. STROBE reporting guidelines were followed. Results At the time of RRT activation, 56% of patients had a documented code status. Code status prevalence was much higher among medical rather than surgical services (74% vs. 13%). For patients escalated to the ICU, having a DNR code status at RRT was not associated with decreased odds of receiving cardioactive medications or advanced respiratory support. Before RRT activation, palliative care utilization was low (9%) but more than doubled after RRT (24% before discharge). Conclusions Barely half of the patients had an active code status at the time of RRT activation. Similar rates of invasive ICU treatments among full code and DNR patients suggest that documented code statuses do not reflect in-depth goals of care discussions, nor does it guide medical teams caring for the patient at times of decompensation.
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Affiliation(s)
- Alexandra Erath
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Kipp Shipley
- Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Erin Burrell
- Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Liza Weavind
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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20
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Richardson DR, Oakes AH, Crossnohere NL, Rathsmill G, Reinhart C, O'Donoghue B, Bridges JFP. Prioritizing the worries of AML patients: Quantifying patient experience using best-worst scaling. Psychooncology 2021; 30:1104-1111. [PMID: 33544421 DOI: 10.1002/pon.5652] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/01/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT Although patients with acute myeloid leukemia (AML) experience significant toxicities and poor outcomes, few studies have quantified patients' experience. METHODS A community-centered approach was used to develop an AML-specific best-worst scaling (BWS) instrument involving 13 items in four domains (psychological, physical, decision-making, and treatment delivery) to quantify patient worry. A survey of patients and caregivers was conducted using the instrument. Data were analyzed using conditional logistic regression. RESULTS The survey was completed by 832 patients and 237 caregivers. Patients were predominantly white (88%), married/partnered (72%), and in remission (95%). The median age was 55 years (range: 19-87). Median time since diagnosis was 8 years (range: 1-40). Patients worried most about "the possibility of dying from AML" (BWS score = 15.5, confidence interval [CI] [14.2-16.7]) and "long-term side effects of treatments" (14.0, CI [12.9-15.2]). Patients found these items more than twice as worrisome as all items within the domains of care delivery and decision-making. Patients were least worried about "communicating openly with doctors" (2.50, CI [1.97-3.04]) and "having access to the best medical care" (3.90, CI [3.28-4.61]). Caregiver reports were highly correlated to patients' (Spearman's ρ = 0.89) though noted significantly more worry about the possibility of dying and spending time in the hospital. CONCLUSION This large convenience sample demonstrates that AML patients have two principal worries: dying from their disease and suffering long-term side effects from treatment. To better foster patient-centered care, therapeutic decision-making and drug development should reflect the importance of both potential outcomes. Further work should explore interventions to address these worries.
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Affiliation(s)
- Daniel R Richardson
- UNC Lineberger Comprehensive Cancer Center, Division of Hematology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Allison H Oakes
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norah L Crossnohere
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA.,Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gary Rathsmill
- Leukemia & Lymphoma Society, White Plains, New York, USA
| | - Crystal Reinhart
- Center for Prevention Research and Development, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | | | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA.,Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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21
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Patel R, Mathew P. An Ethically Justified Approach That Integrates Advance Directives Discussions With Care of the Patient With Cancer. Am J Hosp Palliat Care 2021; 38:1433-1440. [PMID: 33464116 DOI: 10.1177/1049909120988507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although the frequency of advance directives discussions may be increasing, there is a need to improve the quality of these discussions. In a range of advanced medical illnesses, including cancer, poor outcomes with advanced cardiopulmonary life support (ACLS) have been well documented. However, when speaking to patients at the end-of-life, physicians frequently withhold evidence-based information and guidance about prognosis or outcomes of ACLS. Tools and models developed to facilitate communication at the end-of-life do not explicitly include recommendations on advance directives and specifically do not discuss the available evidence on ACLS outcomes in the seriously ill. Here, we review the current literature on outcomes of ACLS and current tools and communications for end-of-life discussions. A majority of patients have a preference for truth-telling and guidance. We advocate an approach that integrates individual goals and preferences with a shared understanding of prognosis and appropriate management options, as judged and recommended by the disease experts, in order to reach an evidence-based decision on advance directives. This pragmatic and ethically justified approach emphasizes active empathic communication to prioritize the care of the patient over the mechanical details of ACLS, thereby aligning end-of-life discussions with current practices in other domains of medicine.
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Affiliation(s)
- Rima Patel
- Department of Medicine, Tufts Medical Center, Boston, MA, USA.,Division of Hematology/Oncology, Mount Sinai Hospital, New York, NY, USA
| | - Paul Mathew
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
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22
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The Experience of Do-Not-Resuscitate Orders and End-of-Life Care Discussions among Physicians. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186869. [PMID: 32962252 PMCID: PMC7559802 DOI: 10.3390/ijerph17186869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/21/2022]
Abstract
Physicians have a responsibility to discuss do-not-resuscitate (DNR) decisions and end-of-life (EOL) care with patients and family members. The aim of this study was to explore the DNR and EOL care discussion experience among physicians in Taiwan. A qualitative study was conducted with 16 physicians recruited from the departments of hospice care, surgery, internal medicine, emergency, and the intensive care unit. The interview guidelines included their DNR experience and process and EOL care discussions, as well as their concerns, difficulties, or worries in discussions. Thematic analysis was used to analyze data. Four themes were identified. First, family members had multiple roles in the decision process. Second, the characteristics of the units, including time urgency and relationships with patients and family members, influenced physicians’ work. Third, the process included preparation, exploration, information delivery, barrier solution, and execution. Fourth, physicians shared reflections on their ability and the conflicts between law, medical professionals, and the best interests of patients. Physicians must consider not only patients’ but also family members’ opinions and surmount several barriers in decision-making. They also experienced negative and positive impacts from these discussions.
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23
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Smith-Uffen MES, Johnson SB, Martin AJ, Tattersall MHN, Stockler MR, Bell ML, Detering K, Clayton JM, Silvester W, Clarke S, Vaccaro L, Beale P, Kiely BE. Estimating survival in advanced cancer: a comparison of estimates made by oncologists and patients. Support Care Cancer 2020; 28:3399-3407. [PMID: 31781946 DOI: 10.1007/s00520-019-05158-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare estimates of expected survival time (EST) made by patients with advanced cancer and their oncologists. METHODS At enrolment patients recorded their "understanding of how long you may have to live" in best-case, most-likely, and worst-case scenarios. Oncologists estimated survival time for each of their patients as the "median survival of a group of identical patients". We hypothesized that oncologists' estimates of EST would be unbiased (~ 50% longer or shorter than the observed survival time [OST]), imprecise (< 33% within 0.67 to 1.33 times OST), associated with OST, and more accurate than patients' estimates of their own survival. RESULTS Twenty-six oncologists estimated EST for 179 patients. The median estimate of EST was 6.0 months, and the median OST was 6.2 months. Oncologists' estimates were unbiased (56% longer than OST), imprecise (27% within 0.67 to 1.33 times OST), and significantly associated with OST (HR 0.88, 95% CI 0.82 to 0.93, p < 0.01). Only 41 patients (23%) provided a numerical estimate of their survival with 107 patients (60%) responding "I don't know". The median estimate by patients for their most-likely scenario was 12 months. Patient estimates of their most-likely scenario were less precise (17% within 0.67 to 1.33 times OST) and more likely to overestimate survival (85% longer than OST) than oncologist estimates. CONCLUSION Oncologists' estimates were unbiased and significantly associated with survival. Most patients with advanced cancer did not know their EST or overestimated their survival time compared to their oncologist, highlighting the need for improved prognosis communication training. Trial registration ACTRN1261300128871.
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Affiliation(s)
- M E S Smith-Uffen
- Department of Cancer Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - S B Johnson
- Department of Cancer Medicine, University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - A J Martin
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - M H N Tattersall
- Department of Cancer Medicine, University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - M R Stockler
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - M L Bell
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - K Detering
- Advance Care Planning Department, Austin Hospital, Melbourne, Victoria, Australia
| | - J M Clayton
- HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Sydney, New South Wales, Australia
- Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Silvester
- University of Melbourne, Melbourne, Victoria, Australia
| | - S Clarke
- Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital Sydney, Sydney, New South Wales, Australia
| | - L Vaccaro
- Department of Cancer Medicine, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, The University of Sydney, Sydney, Australia
| | - P Beale
- Department of Cancer Medicine, University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - B E Kiely
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
- Department of Medical Oncology, Concord Repatriation General Hospital, Concord, NSW, Australia.
- Department of Medical Oncology, Campbelltown Hospital, Campbelltown, New South Wales, Australia.
- NHMRC Clinical Trials Centre, Locked Bag 77, Camperdown, New South Wales, 1450, Australia.
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Bloom-Feshbach K, Goldberg N, Fins JJ. Paternalism, Evangelism, and Power. JOURNAL OF RELIGION AND HEALTH 2020; 59:1258-1272. [PMID: 32318959 DOI: 10.1007/s10943-020-01009-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In medicine and pastoral care, there are parallel struggles with paternalism and evangelism, each exertions of power in the setting of privilege. While striving to avoid abuses of power, well-intentioned professionals may unwittingly abjure providing guidance. This can result in threats to patient care: professional abdication and patient abandonment. In The Healer's Power, Howard Brody conceptualizes an approach to the use of power in therapeutic relationships. In this essay, we invoke Brody's framework to consider the place of evangelism and paternalism in the fields of chaplaincy and medicine in order to promote healing amidst power differentials.
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Affiliation(s)
- Kimberly Bloom-Feshbach
- Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, New York-Presbyterian-Weill Cornell Medical Center, 525 East 68th Street, Box 331, New York, NY, 10065, USA.
| | - Nathan Goldberg
- Department of Spiritual Care and Education, Bridgeport Hospital, Bridgeport, CT, USA
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill-Cornell Medicine, New York, NY, USA
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, CT, USA
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25
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min-SIA: a Lightweight Algorithm to Predict the Risk of 6-Month Mortality at the Time of Hospital Admission. J Gen Intern Med 2020; 35:1413-1418. [PMID: 32157649 PMCID: PMC7210334 DOI: 10.1007/s11606-020-05733-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Predicting death in a cohort of clinically diverse, multi-condition hospitalized patients is difficult. This frequently hinders timely serious illness care conversations. Prognostic models that can determine 6-month death risk at the time of hospital admission can improve access to serious illness care conversations. OBJECTIVE The objective is to determine if the demographic, vital sign, and laboratory data from the first 48 h of a hospitalization can be used to accurately quantify 6-month mortality risk. DESIGN This is a retrospective study using electronic medical record data linked with the state death registry. PARTICIPANTS Participants were 158,323 hospitalized patients within a 6-hospital network over a 6-year period. MAIN MEASURES Main measures are the following: the first set of vital signs, complete blood count, basic and complete metabolic panel, serum lactate, pro-BNP, troponin-I, INR, aPTT, demographic information, and associated ICD codes. The outcome of interest was death within 6 months. KEY RESULTS Model performance was measured on the validation dataset. A random forest model-mini serious illness algorithm-used 8 variables from the initial 48 h of hospitalization and predicted death within 6 months with an AUC of 0.92 (0.91-0.93). Red cell distribution width was the most important prognostic variable. min-SIA (mini serious illness algorithm) was very well calibrated and estimated the probability of death to within 10% of the actual value. The discriminative ability of the min-SIA was significantly better than historical estimates of clinician performance. CONCLUSION min-SIA algorithm can identify patients at high risk of 6-month mortality at the time of hospital admission. It can be used to improved access to timely, serious illness care conversations in high-risk patients.
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26
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Vergo MT, Arnold RM. Learning to Discuss Resuscitation Preferences: As Important as Learning to Resuscitate? J Palliat Med 2020; 23:453-455. [DOI: 10.1089/jpm.2019.0620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Maxwell T. Vergo
- Geisel School of Medicine at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Robert M. Arnold
- UPMC Health System, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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27
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Santivasi WL, Partain DK, Whitford KJ. The role of geriatric palliative care in hospitalized older adults. Hosp Pract (1995) 2020; 48:37-47. [PMID: 31825689 DOI: 10.1080/21548331.2019.1703707] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel K Partain
- Center for Palliative Medicine & Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Center for Palliative Medicine & Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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28
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Rubins JB. Use of Combined Do-Not-Resuscitate/Do-Not Intubate Orders Without Documentation of Intubation Preferences: A Retrospective Observational Study at an Academic Level 1 Trauma Center Code Status and Intubation Preferences. Chest 2020; 158:292-297. [PMID: 32109445 DOI: 10.1016/j.chest.2020.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR. RESEARCH QUESTION How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations? METHODS Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization. RESULTS Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation. CONCLUSIONS Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.
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Affiliation(s)
- Jeffrey B Rubins
- University of Minnesota, Division of Palliative Care, Department of Medicine, Hennepin Healthcare, Minneapolis, MN.
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29
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Fried TR, Street RL, Cohen AB. Chronic Disease Decision Making and "What Matters Most". J Am Geriatr Soc 2020; 68:474-477. [PMID: 32043559 DOI: 10.1111/jgs.16371] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 01/08/2023]
Abstract
The increasing use of the question, "What matters most to you?" is a welcome development in the effort to provide patient-centered care. However, it is difficult for clinicians to translate answers to this question into treatment plans for chronic conditions, including recognizing when to consider options other than clinical practice guideline (CPG)-directed therapy. Goal elicitation is most helpful when a patient has different treatment options with clearly identifiable trade-offs. In the face of trade-offs, goal elicitation helps patients to prioritize among potentially competing outcomes. While decision aids (DAs) focus on trade-offs by delineating options and outcomes, the robust outcome data necessary to create DAs for older patients with multimorbidity are often lacking and even mild cognitive impairment makes the use of DAs difficult. The challenges for providing chronic disease care to older patients who are at risk for adverse events from CPG-directed therapy because of multimorbidity and/or frailty are to organize the complexity of individual combinations of diseases, conditions, and syndromes into common sets of trade-offs and to identify those goals or priorities that will directly inform a plan of care. J Am Geriatr Soc 68:474-477, 2020.
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Affiliation(s)
- Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, Texas.,Department of Medicine, The Houston Center for Quality of Care and Utilization Studies and Baylor College of Medicine, Houston, Texas
| | - Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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30
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Hsu S, Wong SPY. Reconciling Short- and Long-Term Outcomes of In-Hospital Cardiac Arrest in Patients undergoing Maintenance Dialysis. Clin J Am Soc Nephrol 2020; 15:165-167. [PMID: 31911424 PMCID: PMC7015081 DOI: 10.2215/cjn.14121119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Simon Hsu
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; and
| | - Susan P Y Wong
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; and .,Health Services Research and Development Center, VA Puget Sound Health Care System, Seattle, Washington
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31
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Kerkham T, Brain M. Goals of care conversations and documentation in patients triggering medical emergency team calls. Intern Med J 2019; 50:1373-1376. [PMID: 31661181 DOI: 10.1111/imj.14667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is widely accepted that early discussions about goals of care (GOC) should occur during a hospital admission. Whilst rapid response systems such as Medical Emergency Team (MET) calls were designed to identify patients at risk of deterioration early enough in their illness to intervene, it is becoming apparent that these teams frequently diagnose the dying patient. AIMS To determine how frequently Launceston General Hospital MET doctors are involved in discussions surrounding GOC. METHODS A retrospective audit of all MET calls and Code Blues at the Launceston General Hospital over an 18 month period was performed. RESULTS 50% of MET calls occurred in patients with no valid GOC form completed prior. At 3% of events, the GOC form was completed for the first time, and at 3% it was modified. At a further 3% the notes implied there had been a modification to the GOC but the form had not been completed. CONCLUSIONS This audit confirms that documentation surrounding GOC is inadequate, and that at 9% of MET calls, MET doctors are involved in discussions surrounding treatment limitations. This suggests that further education and training is required for doctors working in inpatient care, including those who staff the MET.
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Affiliation(s)
- Telena Kerkham
- Department of General and Acute Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Matthew Brain
- Intensive Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
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Rodenbach R, Kavalieratos D, Tamber A, Tapper C, Resick J, Arnold R, Childers J. Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals-of-Care Conversations. J Palliat Med 2019; 23:220-225. [PMID: 31460823 DOI: 10.1089/jpm.2019.0165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There is increasing need for nonspecialty physicians to deliver palliative care (PC) services to meet patient needs, but many physicians feel inadequately prepared. Objective: We aimed to improve the PC skills of resident physicians through a learner-centered, just-in-time coaching intervention. Design: Our quality improvement initiative consisted of two didactics and brief thrice-weekly coaching sessions that focused on real-time PC questions. Upper level internal medicine residents participated during an inpatient hospitalist rotation. Measurements: Residents completed pre/postrotation surveys of their preparedness in discussing PC topics. Electronic medical record data of documentation of goals-of-care (GOC) discussions and Physician Orders for Life-Sustaining Treatment (POLST) completion in at-risk hospitalized patients (age >65 with two or more hospitalizations in the past six months, or age >90) were obtained and compared with before hospitalization. These data were also compared with data from patients on the same resident hospitalist service during the six-month period before the intervention began. Results: During the 14-month intervention period, 42 residents cared for 232 at-risk patients. Among at-risk patients, 12.9% had a documented GOC discussion before hospitalization, which rose to 57.3% before discharge. Among at-risk patients preintervention, these rates were 5.2% and 25.0%, respectively. Residents reported their preparedness increased across many elements of GOC discussions and rated coaching sessions as useful and relevant to their training. Rates of POLST completion did not differ between preintervention and intervention groups. Conclusions: Brief coaching sessions can integrate PC education into a busy clinical service, improve residents' primary PC skills, and improve GOC documentation.
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Affiliation(s)
- Rachel Rodenbach
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anoo Tamber
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Corey Tapper
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith Resick
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kohen SA, Nair R. Improving hospital-based communication and decision-making about scope of treatment using a standard documentation tool. BMJ Open Qual 2019; 8:e000396. [PMID: 31321314 PMCID: PMC6597658 DOI: 10.1136/bmjoq-2018-000396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 01/26/2019] [Accepted: 03/08/2019] [Indexed: 11/29/2022] Open
Abstract
Background The Vancouver Island Health Authority (VIHA) implemented a standard advance care planning (ACP) document called the medical order for scope of treatment (MOST) in February 2016 to improve end of life communication and documentation. This study aims to see if the MOST implementation improves inpatient ACP documentation when compared with the ‘do not resuscitate’ (DNR) order. Improvement is measured by: (1) proportion of inpatients with documented orders for life-sustaining treatment, (2) discordance between patient’s expressed wishes and chart documentation, (3) patient satisfaction and (4) days admitted to an acute care hospital within 90 days of study inclusion. Methods We performed a single-centre quality improvement study tracking the effects of MOST implementation. 329 consecutive patients were enrolled at a 215-bed community hospital located in Comox, British Columbia, Canada. Results The MOST integrated well into the process of care, significantly improving ACP documentation from 33% preimplementation to 100% over 8 months of implementation. MOST completion was associated with a significant decrease in discordance between patients’ wishes and documented goals of care. Patients with a MOST were significantly older and had a higher charlson comorbidity score than those without a MOST. Despite this, there was no difference in the number of days study patients were admitted to hospital within 90 days of study inclusion. Conclusions MOST implementation improves the frequency and quality of inpatient ACP documentation with no effect on acute care utilisation.
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Affiliation(s)
- Samuel Abuaf Kohen
- Internal Medicine and Critical Care, Comox Valley Hospital, Courtenay, British Columbia, Canada
| | - Rajesh Nair
- Institute on Aging & Lifelong Health, University of Victoria, Victoria, British Columbia, Canada
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Becker C, Lecheler L, Hochstrasser S, Metzger KA, Widmer M, Thommen EB, Nienhaus K, Ewald H, Meier CA, Rueter F, Schaefert R, Bassetti S, Hunziker S. Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e195033. [PMID: 31173119 PMCID: PMC6563579 DOI: 10.1001/jamanetworkopen.2019.5033] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear. OBJECTIVE To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR. DATA SOURCES PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018. STUDY SELECTION Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. DATA EXTRACTION AND SYNTHESIS The study was performed according to the PRISMA guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment. RESULTS Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71). CONCLUSIONS AND RELEVANCE Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
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Affiliation(s)
- Christoph Becker
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Leopold Lecheler
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Seraina Hochstrasser
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Kerstin A. Metzger
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Madlaina Widmer
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Emanuel B. Thommen
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Nienhaus
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University Medical Library, University of Basel, Basel, Switzerland
| | - Christoph A. Meier
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Florian Rueter
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Rainer Schaefert
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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Geerse OP, Lamas DJ, Sanders JJ, Paladino J, Kavanagh J, Henrich NJ, Berendsen AJ, Hiltermann TJN, Fromme EK, Bernacki RE, Block SD. A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer. J Palliat Med 2019; 22:773-781. [PMID: 30724693 DOI: 10.1089/jpm.2018.0487] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. Objective: To characterize the content of serious illness conversations and identify opportunities for improvement. Design: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. Results: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Conclusions: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.
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Affiliation(s)
- Olaf P Geerse
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daniela J Lamas
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin J Sanders
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanna Paladino
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jane Kavanagh
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Natalie J Henrich
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Annette J Berendsen
- 6 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijo J N Hiltermann
- 2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik K Fromme
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D Block
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,7 Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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Turnbull AE, Chessare CM, Coffin RK, Needham DM. More than one in three proxies do not know their loved one's current code status: An observational study in a Maryland ICU. PLoS One 2019; 14:e0211531. [PMID: 30699212 PMCID: PMC6353188 DOI: 10.1371/journal.pone.0211531] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
Rationale The majority of ICU patients lack decision-making capacity at some point during their ICU stay. However the extent to which proxy decision-makers are engaged in decisions about their patient’s care is challenging to quantify. Objectives To assess 1)whether proxies know their patient’s actual code status as recorded in the electronic medical record (EMR), and 2)whether code status orders reflect ICU patient preferences as reported by proxy decision-makers. Methods We enrolled proxy decision-makers for 96 days starting January 4, 2016. Proxies were asked about the patient’s goals of care, preferred code status, and actual code status. Responses were compared to code status orders in the EMR at the time of interview. Characteristics of patients and proxies who correctly vs incorrectly identified actual code status were compared, as were characteristics of proxies who reported a preferred code status that did vs did not match actual code status. Measurements and main results Among 111 proxies, 42 (38%) were incorrect or unsure about the patient’s actual code status and those who were correct vs. incorrect or unsure were similar in age, race, and years of education (P>0.20 for all comparisons). Twenty-nine percent reported a preferred code status that did not match the patient’s code status in the EMR. Matching preferred and actual code status was not associated with a patient’s age, gender, income, admission diagnosis, or subsequent in-hospital mortality or with proxy age, gender, race, education level, or relation to the patient (P>0.20 for all comparisons). Conclusions More than 1 in 3 proxies is incorrect or unsure about their patient’s actual code status and more than 1 in 4 proxies reported that a preferred code status that did not match orders in the EMR. Proxy age, race, gender and education level were not associated with correctly identifying code status or code status concordance.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Rachel K. Coffin
- Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Palathra BC, Kawai F, Oromendia C, Bushan A, Patel Y, Morris J, Pan CX. To Code or Not To Code: Teaching Multidisciplinary Clinicians to Conduct Code Status Discussions. J Palliat Med 2019; 22:566-571. [PMID: 30615558 DOI: 10.1089/jpm.2018.0362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes.
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Affiliation(s)
- Brigit C Palathra
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
| | - Fernando Kawai
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
| | - Clara Oromendia
- 2 Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Archana Bushan
- 3 Department of Medicine, Sinai Hospital, Baltimore, Maryland
| | - Yera Patel
- 4 Department of Medicine, Jamaica Hospital Medical Center, Jamaica, New York
| | - Jane Morris
- 5 Department of Nursing, NewYork-Presbyterian Queens, Flushing, New York
| | - Cynthia X Pan
- 1 Division of Geriatrics and Palliative Care, NewYork-Presbyterian Queens, Flushing, New York
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Escher M, Cullati S, Hudelson P, Nendaz M, Ricou B, Perneger T, Dayer P. Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res 2018; 54:474-483. [PMID: 30362106 DOI: 10.1111/1475-6773.13076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.
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Affiliation(s)
- Monica Escher
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland.,Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Patricia Hudelson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Bara Ricou
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Dayer
- Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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Childers JW, Arnold RM. Expanding Goals of Care Conversations Across a Health System: The Mapping the Future Program. J Pain Symptom Manage 2018; 56:637-644. [PMID: 30048766 DOI: 10.1016/j.jpainsymman.2018.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Clinician failure to discuss goals of care (GOC) with seriously ill patients remains prevalent. Small-scale educational interventions have demonstrated improvement in physician communication skills, but it is unknown if these results translate into practice changes. OBJECTIVES To implement a large-scale educational intervention that would facilitate increased GOC discussions in at-risk patients, increase clinician confidence in having GOC discussions, and prove to be sustainable. METHODS The Mapping the Future courses were four-to-eight-hour trainings, with brief lectures and demonstrations followed by practice with simulated patient cases. Participants completed precourse and postcourse surveys, including demographic information, self-confidence in a variety of communication tasks, willingness to initiate GOC discussions, barriers to GOC discussions, and self-perceived skill at having GOC conversations. We compared the rate of documentation of GOC discussions with at-risk inpatients in three hospitals for physicians who had taken the course and those who had not. RESULTS Over a two-year period, we trained 512 clinicians in 42 sessions. After the course, participants felt that they had improved in all the skills that we taught and agreed that they would be more likely to initiate GOC conversations. Trained physicians were more likely than their nontrained colleagues to document a GOC discussion with at-risk patients (30.8% vs. 27.2%; P = 0.0001). CONCLUSION A large-scale educational intervention involving simulated patient cases increased GOC documentation across a health system. Other programs might consider collaboration with quality improvement specialists to measure the impact of education and situate it within other system changes to support increased GOC discussions.
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Affiliation(s)
- Julie W Childers
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Agarwal R, Epstein AS. Advance Care Planning and End-of-Life Decision Making for Patients with Cancer. Semin Oncol Nurs 2018; 34:316-326. [PMID: 30100366 DOI: 10.1016/j.soncn.2018.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To highlight the importance, challenges, and evolution of advance care planning for patients with cancer. DATA SOURCES Peer-reviewed journal articles and clinical guidelines. CONCLUSION Advance care planning is fundamental to support the personhood of patients with advanced cancer. Patients must be encouraged by physicians and nurses to articulate what matters and provides meaning to them as they live, cope, and receive treatment for their cancer. IMPLICATIONS FOR NURSING PRACTICE Nurses can facilitate advance care planning and primary palliative care, to support patients and families to make informed and value-concordant decisions regarding cancer and end-of-life treatments.
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Abstract
The Declaration of Geneva was recently revised to emphasize patient autonomy and the importance of clinicians sharing medical knowledge. This reflects the welcome evolution of the doctor-patient relationship from one of paternalism to more informed, shared decision-making. Unfortunately, there is an increasing trend for clinicians to avoid making recommendations, instead providing a "menu" of care options from which patients and families must choose. This seems to be underpinned by the belief that it is unacceptably paternalistic to give guidance as to which course of action may be best to take. In this article, we argue that there is an ethical imperative for doctors to provide medical recommendations. This is discussed with particular emphasis on the pediatric critical care setting, where autonomy and shared decision-making are especially complex. We outline how a failure to provide clinical recommendations represents inadequate shared decision-making and erodes the doctor-patient relationship, leading to suboptimal care, paradoxically decreasing respect for autonomy. We describe an approach through which doctors can avoid paternalism without placing an undue burden of decision-making on families. We assert that patients' interests are best served by clinicians taking an active, relational role in shared decision-making, including exploration of values and giving explicit medical recommendations for care.
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Jesus JE, Marshall KD, Kraus CK, Derse AR, Baker EF, McGreevy J. Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU? J Emerg Med 2018; 55:435-440. [PMID: 30054156 DOI: 10.1016/j.jemermed.2018.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 05/17/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. OBJECTIVES In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. DISCUSSION Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. CONCLUSIONS End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.
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Affiliation(s)
| | | | | | | | - Eileen F Baker
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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Stream S, Nolan A, Kwon S, Constable C. Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center. Resuscitation 2018; 130:1-5. [PMID: 29935341 DOI: 10.1016/j.resuscitation.2018.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 06/09/2018] [Accepted: 06/18/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. OBJECTIVE To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DESIGN Retrospective chart review. SETTING/SUBJECTS Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. MEASUREMENTS Logistic regression was used to identify demographic and medical data associated with code status. RESULTS Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). CONCLUSIONS Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.
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Affiliation(s)
- Sara Stream
- New York University Internal Medicine Residency Program, NY, United States
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States; Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States
| | - Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States
| | - Catherine Constable
- Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States; Department of Medicine, New York University Langone Medical Center, NY, United States.
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Coelho CBT, Yankaskas JR. New concepts in palliative care in the intensive care unit. Rev Bras Ter Intensiva 2018; 29:222-230. [PMID: 28977262 PMCID: PMC5496757 DOI: 10.5935/0103-507x.20170031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 09/12/2016] [Indexed: 01/03/2023] Open
Abstract
Some patients admitted to an intensive care unit may face a terminal illness
situation, which usually leads to death. Knowledge of palliative care is
strongly recommended for the health care providers who are taking care of these
patients. In many situations, the patients should be evaluated daily as the
introduction of further treatments may not be beneficial to them. The
discussions among health team members that are related to prognosis and the
goals of care should be carefully evaluated in collaboration with the patients
and their families. The adoption of protocols related to end-of-life patients in
the intensive care unit is fundamental. A multidisciplinary team is important
for determining whether the withdrawal or withholding of advanced care is
required. In addition, patients and families should be informed that palliative
care involves the best possible care for that specific situation, as well as
respect for their wishes and the consideration of social and spiritual
backgrounds. Thus, the aim of this review is to present palliative care as a
reasonable option to support the intensive care unit team in assisting
terminally ill patients. Updates regarding diet, mechanical ventilation, and
dialysis in these patients will be presented. Additionally, the hospice-model
philosophy as an alternative to the intensive care unit/hospital environment
will be discussed.
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Affiliation(s)
| | - James R Yankaskas
- University of North Carolina at Chapel Hill - North Carolina, United States
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Brisebois A, Ismond KP, Carbonneau M, Kowalczewski J, Tandon P. Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care. Hepatology 2018; 67:2025-2040. [PMID: 29251778 DOI: 10.1002/hep.29731] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/28/2017] [Accepted: 12/11/2017] [Indexed: 01/07/2023]
Abstract
UNLABELLED Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. CONCLUSION In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).
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Affiliation(s)
- Amanda Brisebois
- Division of General Internal Medicine, Department of Medicine and Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, AB, Canada.,PPRISM Non-Cancer Palliative Care Clinic, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada
| | - Michelle Carbonneau
- University of Alberta Hospital, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
| | | | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,CEGIIR, University of Alberta, Edmonton, AB, Canada.,Cirrhosis Care Clinic, Edmonton, AB, Canada
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Bader AM. Defining and Ensuring Multidisciplinary High-Quality Patient-Centered Shared Decision-Making for Procedures: a Brief Review of the Current State. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Reversals and limitations on high-intensity, life-sustaining treatments. PLoS One 2018; 13:e0190569. [PMID: 29489814 PMCID: PMC5830043 DOI: 10.1371/journal.pone.0190569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
Importance Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs. Methods This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders. Results 10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28–1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69–2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49–2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27–2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38–1.48] per decade), female (HR 1.30 [95% CI 1.17–1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25–1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48–2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42–1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33–1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15–1.72]). Conclusion Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.
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Bagcivan G, Dionne-Odom JN, Frost J, Plunkett M, Stephens LA, Bishop P, Taylor RA, Li Z, Tucker R, Bakitas M. What happens during early outpatient palliative care consultations for persons with newly diagnosed advanced cancer? A qualitative analysis of provider documentation. Palliat Med 2018; 32:59-68. [PMID: 28952887 DOI: 10.1177/0269216317733381] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early outpatient palliative care consultations are recommended by clinical oncology guidelines globally. Despite these recommendations, it is unclear which components should be included in these encounters. AIM Describe the evaluation and treatment recommendations made in early outpatient palliative care consultations. DESIGN Outpatient palliative care consultation chart notes were qualitatively coded and frequencies tabulated. SETTING/PARTICIPANTS Outpatient palliative care consultations were automatically triggered as part of an early versus delayed randomized controlled trial (November 2010 to April 2013) for patients newly diagnosed with advanced cancer living in the rural Northeastern US. RESULTS In all, 142 patients (early = 70; delayed = 72) had outpatient palliative care consultations. The top areas addressed in these consultations were general evaluations-marital/partner status (81.7%), spirituality/emotional well-being (80.3%), and caregiver/family support (79.6%); symptoms-mood (81.7%), pain (73.9%), and cognitive/mental status (68.3%); general treatment recommendations-counseling (39.4%), maintaining current medications (34.5%), and initiating new medication (23.9%); and symptom-specific treatment recommendations-pain (22.5%), constipation (12.7%), depression (12.0%), advanced directive completion (43.0%), identifying a surrogate (21.8%), and discussing illness trajectory (21.1%). Compared to the early group, providers were more likely to evaluate general pain ( p = 0.035) and hospice awareness ( p = 0.005) and discuss/recommend hospice ( p = 0.002) in delayed group participants. CONCLUSION Outpatient palliative care consultations for newly diagnosed advanced cancer patients can address patients' needs and provide recommendations on issues that might not otherwise be addressed early in the disease course. Future prospective studies should ascertain the value of early outpatient palliative care consultations that are automatically triggered based on diagnosis or documented symptom indicators versus reliance on oncologist referral.
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Affiliation(s)
- Gulcan Bagcivan
- 1 UAB School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA.,2 Gulhane Training and Research Hospital, Ankara, Turkey
| | | | - Jennifer Frost
- 1 UAB School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Margaret Plunkett
- 3 The Center for Nursing Excellence, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lisa A Stephens
- 4 Palliative Care, Sentara Martha Jefferson Hospital, Charlottesville, VA, USA
| | - Peggy Bishop
- 4 Palliative Care, Sentara Martha Jefferson Hospital, Charlottesville, VA, USA
| | - Richard A Taylor
- 1 UAB School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zhongze Li
- 5 Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Rodney Tucker
- 6 UAB Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marie Bakitas
- 1 UAB School of Nursing, The University of Alabama at Birmingham, Birmingham, AL, USA.,6 UAB Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA
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Defining and ensuring multidisciplinary high quality patient-centered shared decision making for procedures – A brief review of current state. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.pcorm.2017.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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