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Rosa WE, Izumi S, Sullivan DR, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D, Tjia J, Cotter V, Wallace C, Sloan DE, Cruz-Oliver DM, DeSanto-Madeya S, Bernacki R, Leblanc TW, Epstein AS. Advance Care Planning in Serious Illness: A Narrative Review. J Pain Symptom Manage 2023; 65:e63-e78. [PMID: 36028176 PMCID: PMC9884468 DOI: 10.1016/j.jpainsymman.2022.08.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. OBJECTIVE To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. METHODS We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. RESULTS Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. CONCLUSIONS We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Shigeko Izumi
- School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine (D.R.S.), School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua Lakin
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Abby R Rosenberg
- Division of Hematology-Oncology, Department of Pediatrics (A.R.R.), University of Washington School of Medicine, Seattle, Washington; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington
| | | | - Debbie Lafond
- Pediatric and Neonatal Needs Advanced (PANDA) Education Consultants (D.L.)
| | - Jennifer Tjia
- Chan Medical School, University of Massachusetts (J.T.), Worcester, Massachusetts
| | - Valerie Cotter
- School of Nursing, Johns Hopkins University (V.C.), Baltimore, Maryland; School of Medicine, Johns Hopkins University (V.C.), Baltimore, Maryland
| | - Cara Wallace
- College for Public Health and Social Justice (C.W.), Saint Louis University, St. Louis, Missouri
| | - Danetta E Sloan
- Department of Health (D.E.S.), Behavior and Society, Johns Hopkins University, Baltimore, Maryland
| | - Dulce Maria Cruz-Oliver
- Geriatric Medicine and Gerontology (D.M.C.O.), Beacham Center for Geriatric Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas W Leblanc
- Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina
| | - Andrew S Epstein
- Department of Medicine (A.S.E.), Memorial Sloan Kettering Cancer Center, New York, New York
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Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
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Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
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Brown CE, Curtis JR, Doll KM. A Race-Conscious Approach Toward Research on Racial Inequities in Palliative Care. J Pain Symptom Manage 2022; 63:e465-e471. [PMID: 34856335 PMCID: PMC9018527 DOI: 10.1016/j.jpainsymman.2021.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022]
Abstract
Racial inequities in palliative and end-of-life care have been well-documented for many years. This inequity is long-standing and resistant to many intervention efforts. One reason for this may be that research in racial inequity in palliative care, and the interventions developed, do not account for the effects of race and the everyday racism that patients of color experience while navigating the healthcare system. Public Health Critical Race Praxis (PHCRP) offers researchers new routes of inquiry to broaden the scope of research priorities in palliative care and improving racial outcomes through a novel conceptual framework and methodology. PHCRP, based off critical race theory (CRT), contains 10 principles within four foci to guide researchers toward a more race conscious approach for the generation of research questions, research processes, and development of interventions targeting racial inequities.
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Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., J.R.C.), University of Washington, Seattle, Washington; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (C.E.B., J.R.C.), University of Washington, Seattle, Washington.
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., J.R.C.), University of Washington, Seattle, Washington; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (C.E.B., J.R.C.), University of Washington, Seattle, Washington
| | - Kemi M Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (K.M.D.), University of Washington, Seattle, Washington
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Lattimer TA, Tenzek KE, Ophir Y, Sullivan SS. Exploring Online Twitter Conversations surrounding National Healthcare Decisions Day and Advance Care Planning from a Socio-Cultural Perspective: A Computational Mixed-Methods Analysis (Preprint). JMIR Form Res 2021; 6:e35795. [PMID: 35416783 PMCID: PMC9047726 DOI: 10.2196/35795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/07/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Within the cultures and societies of the United States, topics related to death and dying continue to be taboo, and as a result, opportunities for presence and engagement during the end of life, which could lead to a good death, are avoided. Several efforts have been made to help people engage in advance care planning (ACP) conversations, including completing advance care directives so that they may express their goals of care if they become too sick to communicate their wishes. A major effort in the United States toward encouraging such challenging discussions is the annual celebration of the National Healthcare Decisions Day. Objective This study aimed to explore ACP from a sociocultural perspective by using Twitter as a communication tool. Methods All publicly available tweets published between August 1, 2020, and July 30, 2021 (N=9713) were collected and analyzed using the computational mixed methods Analysis of Topic Model Network approach. Results The results revealed that conversations driven primarily by laypersons (7107/7410, 95.91% of tweets originated from unverified accounts) surrounded the following three major themes: importance and promotion, surrounding language, and systemic issues. Conclusions On the basis of the results, we argue that there is a need for awareness of the barriers that people may face when engaging in ACP conversations, including systemic barriers, literacy levels, misinformation, policies (including Medicare reimbursements), and trust among health care professionals, in the United States. This is incredibly important for clinicians and scholars worldwide to be aware of as we strive to re-envision ACP, so that people are more comfortable engaging in ACP conversations. In terms of the content of tweets, we argue that there is a chasm between the biomedical and biopsychosocial elements of ACP, including patient narratives. If used properly, Twitter conversations and National Health Care Decision Day hashtags could be harnessed to serve as a connecting point among organizations, physicians, patients, and family members to lay the groundwork for the trajectory toward a good death.
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Affiliation(s)
- Tahleen A Lattimer
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Kelly E Tenzek
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Yotam Ophir
- Department of Communication, University at Buffalo, SUNY, East Amherst, NY, United States
| | - Suzanne S Sullivan
- School of Nursing, University at Buffalo, SUNY, East Amherst, NY, United States
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Mann CM, Sullivan SS. Promoting Evidence-Based Practice in Clinical Education at a Hospice Designated Education Unit. J Hosp Palliat Nurs 2021; 23:354-359. [PMID: 33797453 DOI: 10.1097/njh.0000000000000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Integration of palliative care principles into undergraduate nursing curriculum is essential to prepare students to provide supportive care services across the continuum of care for individuals with serious illness. Baccalaureate nursing curricula emphasize development and application of evidence-based practice (EBP); however, development of nursing skills often overshadows teaching students how to deliver care or facilitate practice changes based on evidence in clinical education. Problems revealed in clinical practice are a valuable tool for improving student use and appreciation of EBP in clinical settings. The EBP project presented in this article provides a process to promote palliative and end-of-life EBP in clinical education. This project highlights the proposed American Association of Colleges of Nursing hospice/palliative/supportive care sphere of care in a hospice dedicated education unit following The Seven Steps of EBP. Students participating in the project developed core skills to search, appraise, and translate evidence and the ability to lead EBP projects guided by the dedicated education unit model. Dedicated education units serve as ideal clinical education sites to develop student EBP competencies and support transition to practice through collaboration with practice partner stakeholders.
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6
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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7
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Ashana DC, D’Arcangelo N, Gazarian PK, Gupta A, Perez S, Reich AJ, Tjia J, Halpern SD, Weissman JS, Ladin K. "Don't Talk to Them About Goals of Care": Understanding Disparities in Advance Care Planning. J Gerontol A Biol Sci Med Sci 2021; 77:339-346. [PMID: 33780534 PMCID: PMC8824574 DOI: 10.1093/gerona/glab091] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. METHOD In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. RESULTS Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences). CONCLUSIONS Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.
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Affiliation(s)
- Deepshikha Charan Ashana
- Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA,Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Noah D’Arcangelo
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts, USA
| | - Priscilla K Gazarian
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Avni Gupta
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA,Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, USA
| | - Stephen Perez
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA,Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts, USA,Department of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA,Address correspondence to: Keren Ladin, PhD, MSc, Department of Community Health, Tufts University, 574 Boston Avenue, Suite 216, Medford, MA 02155, USA. E-mail:
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8
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Henke C, Mroz E, Le NA, Gregory HM, Ghiaseddin A, McFarland NR, Baron-Lee J. Introducing a Supportive Care Team for Advance Directive Education in a Neurological and Neurosurgical Patient Population. J Patient Exp 2020; 7:1286-1293. [PMID: 33457577 PMCID: PMC7786676 DOI: 10.1177/2374373520932449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Patient-centered care includes delineation of patient treatment values (ie, advance care planning [ACP]). Advance care planning often includes advance directive (AD) completion and is underutilized, particularly among neurology and neurosurgery patients. Implementation of a supportive care team (SCT) in outpatient clinic settings may offer opportunities for AD education and completion. Objective: This study assesses the effectiveness of an integrative SCT composed of hospice volunteers and undergraduate quality improvement interns in their efforts to provide ACP education in neurological and neurosurgical outpatient clinics. Assessment includes a description of different types of SCT-patient encounters, as well as patient interest in and completion of ADs after interacting with the SCT. Results: Across the data collection period, 2770 encounters were initiated. The majority of encounters resulted in patient ACP education. Some patients completed ADs during their SCT encounter (3.45%) or after their SCT encounter (10.18%). Conclusion: The SCT effectively enhances ACP education in this patient population. The utilization of trained interns to assist with ACP is beneficial and practical in clinic workflow.
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Affiliation(s)
- Charlotte Henke
- Department of Neurology, University of Florida, Gainesville, FL, USA.,These authors contributed equally to this work
| | - Emily Mroz
- Department of Neurology, University of Florida, Gainesville, FL, USA.,Department of Psychology, University of Florida, Gainesville, FL, USA.,These authors contributed equally to this work
| | - Ngoc Anh Le
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Hannah M Gregory
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Ashley Ghiaseddin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Nikolaus R McFarland
- Department of Neurology, University of Florida, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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Lee RY, Brumback LC, Sathitratanacheewin S, Lober WB, Modes ME, Lynch YT, Ambrose CI, Sibley J, Vranas KC, Sullivan DR, Engelberg RA, Curtis JR, Kross EK. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life. JAMA 2020; 323:950-960. [PMID: 32062674 PMCID: PMC7042829 DOI: 10.1001/jama.2019.22523] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. OBJECTIVES To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. EXPOSURES POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. MAIN OUTCOMES AND MEASURES The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. RESULTS Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). CONCLUSIONS AND RELEVANCE Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - William B. Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Matthew E. Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Ylinne T. Lynch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | | | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Kelly C. Vranas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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10
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Sullivan SS, Klingman KJ. Advance care planning associated with demographics but not necessarily preferences: A cross-sectional analysis of NHATS data. Appl Nurs Res 2019; 49:97-103. [PMID: 30979524 DOI: 10.1016/j.apnr.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Suzanne S Sullivan
- School of Nursing, University at Buffalo, The State University of New York, United States of America.
| | - Karen J Klingman
- College of Nursing, State University of New York, Upstate Medical University, United States of America
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