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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024:S0012-3692(24)00153-3. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [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: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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2
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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Tong W, Murali KP, Fonseca LD, Blinderman CD, Shelton RC, Hua M. Interpersonal Conflict between Clinicians in the Delivery of Palliative and End-of-Life Care for Critically Ill Patients: A Secondary Qualitative Analysis. J Palliat Med 2022; 25:1501-1509. [PMID: 35363575 PMCID: PMC9529295 DOI: 10.1089/jpm.2021.0631] [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] [Accepted: 03/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Conflict between clinicians is prevalent within intensive care units (ICUs) and may hinder optimal delivery of care. However, little is known about the sources of interpersonal conflict and how it manifests within the context of palliative and end-of-life care delivery in ICUs. Objective: To characterize interpersonal conflict in the delivery of palliative care within ICUs. Design: Secondary thematic analysis using a deductive-inductive approach. We analyzed existing qualitative data that conducted semistructured interviews to examine factors associated with variable adoption of specialty palliative care in ICUs. Settings/Subjects: In the parent study, 36 participants were recruited from two urban academic medical centers in the United States, including ICU attendings (n = 17), ICU nurses (n = 11), ICU social workers (n = 1), and palliative care providers (n = 7). Measurements: Coders applied an existing framework of interpersonal conflict to guide initial coding and analysis, combined with a flexible inductive approach allowing new codes to emerge. Results: We characterized three properties of interpersonal conflict: disagreement, interference, and negative emotion. In the context of delivering palliative and end-of-life care for critically ill patients, "disagreement" centered around whether patients were appropriate for palliative care, which care plans should be prioritized, and how care should be delivered. "Interference" involved preventing palliative care consultation or goals-of-care discussions and hindering patient care. "Negative emotion" included occurrences of silencing or scolding, rudeness, anger, regret, ethical conflict, and grief. Conclusions: Our findings provide an in-depth understanding of interpersonal conflict within palliative and end-of-life care for critically ill patients. Further study is needed to understand how to prevent and resolve such conflicts.
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Affiliation(s)
- Wendy Tong
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Komal P. Murali
- School of Nursing, Columbia University, New York, New York, USA
| | - Laura D. Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Craig D. Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences and Columbia University Mailman School of Public Health, New York, New York, USA
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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4
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Akkermans AA, Lamerichs JMWJJ, Schultz MJM, Cherpanath TGVT, van Woensel JBMJ, van Heerde MM, van Kaam AHLCA, van de Loo MDM, Stiggelbout AMA, Smets EMAE, de Vos MAM. How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study. Palliat Med 2021; 35:1865-1877. [PMID: 34176357 PMCID: PMC8637379 DOI: 10.1177/02692163211028079] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach. AIM To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care. DESIGN Exploratory inductive thematic analysis of 101 audio-recorded conversations. SETTING/PARTICIPANTS One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated. RESULTS We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences. CONCLUSIONS Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.
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Affiliation(s)
- A Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J M W J Joyce Lamerichs
- Faculty of Humanities, Department of Language, Literature and Communication, VU Amsterdam, Amsterdam, The Netherlands
| | - M J Marcus Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - T G V Thomas Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J B M Job van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A H L C Anton van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M D Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, the Netherlands
| | - E M A Ellen Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A Mirjam de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Putting Prognosis First: Impact of an Intensive Care Unit Team Premeeting Curriculum. ATS Sch 2021; 2:386-396. [PMID: 34667988 PMCID: PMC8519315 DOI: 10.34197/ats-scholar.2020-0063oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The paradigm of care has shifted in the pediatric intensive care unit (ICU) such that patients are frequently cared for by teams of specialists rather than the ICU attending physician solely managing care. An unintended consequence of care managed by multiple specialists is that families often receive conflicting messages from different team members, with little focus on disclosing prognosis. Objective: To address this gap, we developed and pilot-tested a team communication skills training (CST) program focused on the healthcare team premeeting in which roles, purpose, and prognosis are clarified before meeting with the family. Our aim was to assess whether the team CST program was associated with increased discussion of prognosis during the team premeeting. Methods: We conducted a single-center, observational pilot study to develop and test a team CST program using a before/after design. Pediatric ICU physicians and specialists from pediatric neurology and pediatric oncology who co-led family conferences in the pediatric ICU participated in a 1-day team CST program. Team premeetings were audio-recorded and transcribed. Results: We analyzed seven pre- and 10 post-CST program audio-recorded team premeetings, which each compromised a median of eight healthcare team members. Prognosis was more likely to be discussed in post-CST team premeetings (10/10 vs. 3/7; P = 0.0147). Agreement on prognosis was achieved more frequently in post-CST teams compared with pre-CST teams, although the percentage of agreement did not reach significance (9/10 vs. 3/7; P = 0.1007). Conclusions: A CST program with a structured approach to conducting a team premeeting was associated with an increased discussion of prognosis among team members before convening with the family in the pediatric ICU.
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Douplat M, Fraticelli L, Claustre C, Peiretti A, Serre P, Bischoff M, Jacquin L, Freyssenge J, Schott AM, Tazarourte K, Frugier S, Khoury CEL, Grezard M, Antoine JD, Dumont O, Lhuillier E, Pierro L, Blain S, Prost C, Sen-Brachet P, Khaldi A. Management of decision of withholding and withdrawing life-sustaining treatments in French EDs. Scand J Trauma Resusc Emerg Med 2020; 28:52. [PMID: 32513282 PMCID: PMC7282105 DOI: 10.1186/s13049-020-00744-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature.
Study objective
We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France.
Method
In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process.
Results
There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives.
Conclusion
The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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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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Cardona M, Anstey M, Lewis ET, Shanmugam S, Hillman K, Psirides A. Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic. Breathe (Sheff) 2020; 16:200062. [PMID: 33304408 PMCID: PMC7714540 DOI: 10.1183/20734735.0062-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/08/2020] [Indexed: 12/31/2022] Open
Abstract
The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity. KEY POINTS The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted. EDUCATIONAL AIMS To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.
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Affiliation(s)
- Magnolia Cardona
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
- Gold Coast Hospital and Health Service, Southport, Australia
| | - Matthew Anstey
- Intensive Care Medicine, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Ebony T. Lewis
- School of Public Health and Community Medicine, The University of New South Wales, Kensington, Australia
| | | | - Ken Hillman
- Intensive Care Unit, Liverpool Hospital, Liverpool, Australia
| | - Alex Psirides
- Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
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10
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Ali SK, Nambafu J, Daroowalla F. Fostering productive conversations in a Kenyan tertiary intensive care unit: lessons learnt. Pan Afr Med J 2019; 34:104. [PMID: 31934247 PMCID: PMC6945388 DOI: 10.11604/pamj.2019.34.104.20526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 11/11/2022] Open
Abstract
Effective communication remains key in delivery of comprehensive care to patient especially in the intensive care unit (ICU) setting. However, many providers, for various reasons, struggle with the art of effective communication adversely affecting relationship with patients and their families. Little is known or has been published about effective communication in ICUs within sub-Saharan Africa.
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Affiliation(s)
- Sayed Karar Ali
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Jamila Nambafu
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Feroza Daroowalla
- Department of Medicine, University of Central Florida, College of Medicine, Orlando, Florida, USA
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Advance Care Planning and Parent-Reported End-of-Life Outcomes in Children, Adolescents, and Young Adults With Complex Chronic Conditions. Crit Care Med 2019; 47:101-108. [PMID: 30303834 DOI: 10.1097/ccm.0000000000003472] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES For children, adolescents, and young adults with complex chronic conditions advance care planning may be a vital component of optimal care. Advance care planning outcomes research has previously focused on seriously ill adults and adolescents with cancer where it is correlated with high-quality end-of-life care. The impact of advance care planning on end-of-life outcomes for children, adolescents, and young adults with complex chronic conditions is unknown, thus we sought to evaluate parental preferences for advance care planning and to determine whether advance care planning and assessment of specific family considerations during advance care planning were associated with differences in parent-reported end-of-life outcomes. DESIGN Cross-sectional survey. SETTING Large, tertiary care children's hospital. SUBJECTS Bereaved parents of children, adolescents, and young adults with complex chronic conditions who died between 2006 and 2015. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One-hundred fourteen parents were enrolled (54% response rate) and all parents reported that advance care planning was important, with a majority (70%) endorsing that discussions should occur early in the illness course. Parents who reported advance care planning (65%) were more likely to be prepared for their child's last days of life (adjusted odds ratio, 3.78; 95% CI, 1.33-10.77), to have the ability to plan their child's location of death (adjusted odds ratio, 2.93; 95% CI, 1.06-8.07), and to rate their child's quality of life during end-of-life as good to excellent (adjusted odds ratio, 3.59; 95% CI, 1.23-10.37). Notably, advance care planning which included specific assessment of family goals was associated with a decrease in reported child suffering at end-of-life (adjusted odds ratio, 0.23; 95% CI, 0.06-0.86) and parental decisional regret (adjusted odds ratio, 0.42; 95% CI, 0.02-0.87). CONCLUSIONS Parents of children, adolescents, and young adults with complex chronic conditions highly value advance care planning, early in the illness course. Importantly, advance care planning is associated with improved parent-reported end-of-life outcomes for this population including superior quality of life. Further studies should evaluate strategies to ensure high-quality advance care planning including specific assessment of family goals.
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12
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Teixeira C, Cardoso PRC. How to discuss about do-not-resuscitate in the intensive care unit? Rev Bras Ter Intensiva 2019; 31:386-392. [PMID: 31618359 PMCID: PMC7005960 DOI: 10.5935/0103-507x.20190051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/27/2018] [Indexed: 11/23/2022] Open
Abstract
The improvement in cardiopulmonary resuscitation quality has reduced the mortality of individuals treated for cardiac arrest. However, survivors have a high risk of severe brain damage in cases of return of spontaneous circulation. Data suggest that cases of cardiac arrest in critically ill patients with non-shockable rhythms have only a 6% chance of returning of spontaneous circulation, and of these, only one-third recover their autonomy. Should we, therefore, opt for a procedure in which the chance of survival is minimal and the risk of hospital death or severe and definitive brain damage is approximately 70%? Is it worth discussing patient resuscitation in cases of cardiac arrest? Would this discussion bring any benefit to the patients and their family members? Advanced discussions on do-not-resuscitate are based on the ethical principle of respect for patient autonomy, as the wishes of family members and physicians often do not match those of patients. In addition to the issue of autonomy, advanced discussions can help the medical and care team anticipate future problems and, thus, better plan patient care. Our opinion is that discussions regarding the resuscitation of critically ill patients should be performed for all patients within the first 24 to 48 hours after admission to the intensive care unit.
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Affiliation(s)
- Cassiano Teixeira
- Departamento de Medicina Interna e Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil.,Departamento de Medicina Interna, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Paulo Ricardo Cerveira Cardoso
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Lewis ET, Harrison R, Hanly L, Psirides A, Zammit A, McFarland K, Dawson A, Hillman K, Barr M, Cardona M. End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation. Health Expect 2019; 22:405-414. [PMID: 30614161 PMCID: PMC6543262 DOI: 10.1111/hex.12860] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 12/01/2022] Open
Abstract
Background As older adults approach the end‐of‐life (EOL), many are faced with complex decisions including whether to use medical advances to prolong life. Limited information exists on the priorities of older adults at the EOL. Objective This study aimed to explore patient and family experiences and identify factors deemed important to quality EOL care. Method A descriptive qualitative study involving three focus group discussions (n = 18) and six in‐depth interviews with older adults suffering from either a terminal condition and/or caregivers were conducted in NSW, Australia. Data were analysed thematically. Results Seven major themes were identified as follows: quality as a priority, sense of control, life on hold, need for health system support, being at home, talking about death and competent and caring health professionals. An underpinning priority throughout the seven themes was knowing and adhering to patient's wishes. Conclusion Our study highlights that to better adhere to EOL patient's wishes a reorganization of care needs is required. The readiness of the health system to cater for this expectation is questionable as real choices may not be available in acute hospital settings. With an ageing population, a reorganization of care which influences the way we manage terminal patients is required.
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Affiliation(s)
- Ebony T Lewis
- Faculty of Medicine, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Reema Harrison
- Faculty of Medicine, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Laura Hanly
- SWS Clinical School, The Simpson Centre for Health Services Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Alex Psirides
- Department of Intensive Care Medicine, Wellington Regional Hospital, Wellington, New Zealand.,University of Otago, Wellington, New Zealand
| | | | - Kathryn McFarland
- Cunningham Centre for Palliative Care, Sacred Heart Health Service, St Vincent's Health Network, Sydney, New South Wales, Australia
| | - Angela Dawson
- Faculty of Health, The Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Ken Hillman
- SWS Clinical School, The Simpson Centre for Health Services Research, University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Margo Barr
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Magnolia Cardona
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
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Bibler TM, Shinall MC, Stahl D. Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:40-51. [PMID: 29697329 DOI: 10.1080/15265161.2018.1431702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, "How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?" We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.
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Patterns of Care at the End of Life for Children and Young Adults with Life-Threatening Complex Chronic Conditions. J Pediatr 2018; 193:196-203.e2. [PMID: 29174080 PMCID: PMC5794525 DOI: 10.1016/j.jpeds.2017.09.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/14/2017] [Accepted: 09/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions (LT-CCCs) and to compare them by LT-CCC type. STUDY DESIGN Cross-sectional survey of bereaved parents (n = 114; response rate of 54%) of children with noncancer, noncardiac LT-CCCs who received care at a quaternary care children's hospital and medical record abstraction. RESULTS The majority of children with LT-CCCs died in the hospital (62.7%) with more than one-half (53.3%) dying in the intensive care unit. Those with static encephalopathy (AOR, 0.19; 95% CI, 0.04-0.98), congenital and chromosomal disorders (AOR, 0.28; 95% CI, 0.09-0.91), and pulmonary disorders (AOR, 0.08; 95% CI, 0.01-0.77) were significantly less likely to die at home compared with those with progressive central nervous system (CNS) disorders. Almost 50% of patients died after withdrawal or withholding of life-sustaining therapies, 17.5% died during active resuscitation, and 36% died while receiving comfort care only. The mode of death varied widely across LT-CCCs, with no patients with pulmonary disorders dying receiving comfort care only compared with 66.7% of those with CNS progressive disorders. A majority of patients had palliative care involvement (79.3%); however, in multivariable analyses, there was distinct variation in receipt of palliative care across LT-CCCs, with patients having CNS static encephalopathy (AOR, 0.07; 95% CI, 0.01-0.68) and pulmonary disorders (AOR, 0.07; 95% CI, 0.01-.09) significantly less likely to have palliative care involvement than those with CNS progressive disorders. CONCLUSIONS Significant differences in patterns of care at the end of life exist depending on LT-CCC type. Attention to these patterns is important to ensure equal access to palliative care and targeted improvements in end-of-life care for these populations.
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Gofton TE, Chum M, Schulz V, Gofton BT, Sarpal A, Watling C. Challenges facing palliative neurology practice: A qualitative analysis. J Neurol Sci 2017; 385:225-231. [PMID: 29277430 DOI: 10.1016/j.jns.2017.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aimed to develop a conceptual understanding of the specific characteristics of palliative care in neurology and the challenges of providing palliative care in the setting of neurological illness. METHOD The study was conducted at London Health Sciences Centre in Canada using grounded theory methodology. Qualitative thematic analysis was applied to focus group (health care providers physicians, nursing, allied health, trainees) and semi-structured interview (patient-caregiver dyads) data to explore challenges facing the delivery of palliative care in neurology. RESULTS Specific characteristics of neurological disease that affect palliative care in neurology were identified: 1) timelines of disease progression, 2) barriers to communication arising from neurologic disease, 3) variability across disease progression, and 4) threat to personhood arising from functional and cognitive impairments related to neurologic disease. Moreover, three key challenges that shaped and complicated palliative care in neurology were identified: 1) uncertainty with respect to prognosis, support availability and disease trajectory, 2) inconsistency in information, attitudes and skills among care providers, care teams, caregivers and families, and 3) existential distress specific to neurological disease, including emotional, psychological and spiritual distress resulting from loss of function, autonomy and death. These challenges were experienced across groups, but manifested themselves in different ways for each group. CONCLUSIONS Further research regarding prognosis, improved identification of patients with palliative care needs, developing an approach to palliative care delivery within neurology and the creation of more robust educational resources for teaching palliative neurology are expected to improve neurologists' comfort with palliative care, thereby enhancing care delivery in neurology.
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Affiliation(s)
- T E Gofton
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Department of Critical Care, Western University, London, Ontario, Canada.
| | - M Chum
- Division of Neurology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Canada
| | - V Schulz
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | | | - A Sarpal
- Department of Pediatrics, Western University, London, Ontario, Canada
| | - C Watling
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
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17
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Mullen JE, Reynolds MR, Larson JS. Caring for Pediatric Patients' Families at the Child's End of Life. Crit Care Nurse 2017; 35:46-55; quiz 56. [PMID: 26628545 DOI: 10.4037/ccn2015614] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Nurses play an important role in supporting families who are faced with the critical illness and death of their child. Grieving families desire compassionate, sensitive care that respects their wishes and meets their needs. Families often wish to continue relationships and maintain lasting connections with hospital staff following their child's death. A structured bereavement program that supports families both at the end of their child's life and throughout their grief journey can meet this need.
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Affiliation(s)
- Jodi E Mullen
- Jodi E. Mullen is a clinical leader, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital, Gainesville, Florida.Melissa R. Reynolds is a nurse manager, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital.Jennifer S. Larson is an advanced hospice and palliative social worker in pediatric hematology/oncology, University of Florida Health, Shands Children's Hospital.
| | - Melissa R Reynolds
- Jodi E. Mullen is a clinical leader, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital, Gainesville, Florida.Melissa R. Reynolds is a nurse manager, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital.Jennifer S. Larson is an advanced hospice and palliative social worker in pediatric hematology/oncology, University of Florida Health, Shands Children's Hospital
| | - Jennifer S Larson
- Jodi E. Mullen is a clinical leader, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital, Gainesville, Florida.Melissa R. Reynolds is a nurse manager, pediatric intensive care unit, University of Florida Health, Shands Children's Hospital.Jennifer S. Larson is an advanced hospice and palliative social worker in pediatric hematology/oncology, University of Florida Health, Shands Children's Hospital
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18
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Bond WF, Gonzalez HC, Funk AM, Fehr LS, McGarvey JS, Svendsen JD, Sawicki R. Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators. J Palliat Med 2017; 20:631-637. [PMID: 28085541 DOI: 10.1089/jpm.2016.0431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Multimodal curricular assessment after adding standardized patient (SP) actor-based simulation to an advance care planning (ACP) facilitator training course and development of a formative feedback tool. BACKGROUND ACP represents a highly valued service requiring more and better trained facilitators. METHODS Participants were primarily nurses and social workers in a large multisite health system. The course included a precourse video demonstration of ACP, traditional lectures, and four 30-minute simulations with SPs. Knowledge was tested with a multiple choice question (MCQ) test. In addition to standard postcourse/postsimulation evaluations, learners were surveyed pre/post/30-90 days delayed for self-perceived confidence. A linear mixed-effects model was used to analyze changes over time. Trained faculty rated performance in simulations with an observational mini-clinical examination (mini-CEX)-type rating form with a checklist, global competency, and global communication rating. Inter-rater reliability (IRR) was calculated on randomly selected paired ratings. RESULTS Sixty-seven individuals consented to participate. MCQ scores improved from 83% ± 10% to 92% ± 8% (p < 0.001). Paired learner surveys of self-confidence across six domains were available for 65 pre, 65 post, and 40 delayed with a mean positive change on a 0 to 10 point scale from pre-post (2.32 ± 1.65; p < 0.001) and predelayed (2.34 ± 1.96; p < 0.001) time frames. For the faculty observation ratings of simulation performance, the average raw agreement for critical actions was 82% and IRR was 0.71. CONCLUSIONS Learner feedback and self-assessment suggest that actor-based simulation contributed to improved confidence in conducting ACP. The mini-CEX observation form is adequate for formative feedback, with further testing needed to make judgments of competence.
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Affiliation(s)
- William F Bond
- 1 OSF HealthCare , Peoria, Illinois.,2 Jump Simulation , Peoria, Illinois.,3 University of Illinois College of Medicine at Peoria , Peoria, Illinois
| | - Hanna C Gonzalez
- 3 University of Illinois College of Medicine at Peoria , Peoria, Illinois
| | - Amy M Funk
- 4 Illinois Wesleyan University , Bloomington, Illinois
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Learning by (video) example: a randomized study of communication skills training for end-of-life and error disclosure family care conferences. Am J Surg 2016; 212:996-1004. [DOI: 10.1016/j.amjsurg.2016.02.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 02/18/2016] [Accepted: 02/27/2016] [Indexed: 11/18/2022]
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20
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Rasmussen LA, Bell E, Racine E. A Qualitative Study of Physician Perspectives on Prognostication in Neonatal Hypoxic Ischemic Encephalopathy. J Child Neurol 2016; 31:1312-9. [PMID: 27377309 DOI: 10.1177/0883073816656400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
Hypoxic ischemic encephalopathy is the most frequent cause of neonatal encephalopathy and yields a great degree of morbidity and mortality. From an ethical and clinical standpoint, neurological prognosis is fundamental in the care of neonates with hypoxic ischemic encephalopathy. This qualitative study explores physician perspectives about neurological prognosis in neonatal hypoxic ischemic encephalopathy. This study aimed, through semistructured interviews with neonatologists and pediatric neurologists, to understand the practice of prognostication. Qualitative thematic content analysis was used for data analysis. The authors report 2 main findings: (1) neurological prognosis remains fundamental to quality-of-life predictions and considerations of best interest, and (2) magnetic resonance imaging is presented to parents with a greater degree of certainty than actually exists. Further research is needed to explore both the parental perspective and, prospectively, the impact of different clinical approaches and styles to prognostication for neonatal hypoxic ischemic encephalopathy.
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Affiliation(s)
- Lisa Anne Rasmussen
- McGill University, Montréal, Québec, Canada Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Emily Bell
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Eric Racine
- McGill University, Montréal, Québec, Canada Institut de recherches cliniques de Montréal, Montréal, Québec, Canada Université de Montréal, Montréal, Québec, Canada
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21
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Grady PA. Advancing palliative and end-of-life science in cardiorespiratory populations: The contributions of nursing science. Heart Lung 2016; 46:3-6. [PMID: 27612388 DOI: 10.1016/j.hrtlng.2016.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/28/2016] [Accepted: 07/22/2016] [Indexed: 11/28/2022]
Abstract
Nursing science has a critical role to inform practice, promote health, and improve the lives of individuals across the lifespan who face the challenges of advanced cardiorespiratory disease. Since 1997, the National Institute of Nursing Research (NINR) has focused attention on the importance of palliative and end-of-life care for advanced heart failure and advanced pulmonary disease through the publication of multiple funding opportunity announcements and by supporting a cadre of nurse scientists that will continue to address new priorities and future directions for advancing palliative and end-of-life science in cardiorespiratory populations.
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Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians. Ann Am Thorac Soc 2016; 12:1646-53. [PMID: 26452172 DOI: 10.1513/annalsats.201507-408oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Therapeutic alliance is a novel measure of the multifaceted caregiver-clinician relationship and a promising intervention target for improving patient-centered outcomes. However, therapeutic alliance has not been studied in an intensive care unit (ICU) setting. OBJECTIVES To explore the relationships among caregiver-reported therapeutic alliance and psychological distress as well as patient, caregiver, and ICU clinician factors. METHODS In this cross-sectional study, we enrolled consecutive patient caregivers of mechanically ventilated patients discharged from all ICUs at Duke University and the Medical University of South Carolina Hospitals between December 2013 and August 2014. MEASUREMENTS AND MAIN RESULTS Caregivers completed an in-person, hospital-based interview that included measures of therapeutic alliance with the ICU physicians (Human Connection Scale) as well as patient centeredness of care; symptoms of depression, anxiety, and post-traumatic stress; decisional conflict; and quality of communication. We performed a multivariate regression to characterize associations between Human Connection Scale scores and key variables. A total of 56 caregivers were included in these exploratory analyses. Patients were largely disabled (47%) and Medicare insured (53%). Caregivers were highly educated and generally had high therapeutic alliance (median, 55; interquartile range, 48-58) with the ICU clinicians. Therapeutic alliance was strongly correlated with patient centeredness (r = 0.78) and poorly correlated with psychological distress (r < 0.2). Stepwise multivariate modeling revealed that higher therapeutic alliance was associated with fewer baseline patient comorbidities as well as caregiver report of greater trust in the ICU team, better quality of communication, and less decisional conflict (all P < 0.012). CONCLUSIONS Therapeutic alliance encompasses measures of trust, communication, and cooperation, which are intuitive to forming a good working relationship. Therapeutic alliance among ICU caregivers is strongly associated with both modifiable and nonmodifiable factors. Our exploratory study highlights new intervention targets that may inform strategies for improving the quality of the caregiver-clinician interaction.
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Leland BD, Torke AM, Wocial LD, Helft PR. Futility Disputes: A Review of the Literature and Proposed Model for Dispute Navigation Through Trust Building. J Intensive Care Med 2016; 32:523-527. [PMID: 27568477 DOI: 10.1177/0885066616666001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Futility disputes in the intensive care unit setting have received significant attention in the literature over the past several years. Although the idea of improving communication in an attempt to resolve these challenging situations has been regularly discussed, the concept and role of trust building as the means by which communication improves and disputes are best navigated is largely absent. We take this opportunity to review the current literature on futility disputes and argue the important role of broken trust in these encounters, highlighting current evidence establishing the necessity and utility of trust in both medical decision-making and effective communication. Finally, we propose a futility dispute navigation model built upon improved communication through trust building.
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Affiliation(s)
- Brian D Leland
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,2 Department of Pediatrics, Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexia M Torke
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,3 Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.,4 Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indiana University Health, Indianapolis, IN, USA
| | - Lucia D Wocial
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,5 Indiana University School of Nursing, Indianapolis, IN, USA
| | - Paul R Helft
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,6 Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Reblin M, Clayton MF, John KK, Ellington L. Addressing Methodological Challenges in Large Communication Data Sets: Collecting and Coding Longitudinal Interactions in Home Hospice Cancer Care. HEALTH COMMUNICATION 2016; 31:789-97. [PMID: 26580414 PMCID: PMC4853241 DOI: 10.1080/10410236.2014.1000480] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
In this article, we present strategies for collecting and coding a large longitudinal communication data set collected across multiple sites, consisting of more than 2000 hours of digital audio recordings from approximately 300 families. We describe our methods within the context of implementing a large-scale study of communication during cancer home hospice nurse visits, but this procedure could be adapted to communication data sets across a wide variety of settings. This research is the first study designed to capture home hospice nurse-caregiver communication, a highly understudied location and type of communication event. We present a detailed example protocol encompassing data collection in the home environment, large-scale, multisite secure data management, the development of theoretically-based communication coding, and strategies for preventing coder drift and ensuring reliability of analyses. Although each of these challenges has the potential to undermine the utility of the data, reliability between coders is often the only issue consistently reported and addressed in the literature. Overall, our approach demonstrates rigor and provides a "how-to" example for managing large, digitally recorded data sets from collection through analysis. These strategies can inform other large-scale health communication research.
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Affiliation(s)
- Maija Reblin
- a Department of Health Outcomes & Behavior , Moffitt Cancer Center
| | | | - Kevin K John
- c School of Communications , Brigham Young University
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25
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October TW, Hinds PS, Wang J, Dizon ZB, Cheng YI, Roter DL. Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences. Pediatr Crit Care Med 2016; 17:490-7. [PMID: 27058750 PMCID: PMC4893980 DOI: 10.1097/pcc.0000000000000719] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU. DESIGN Single-site, cross-sectional study. SETTING Forty-four-bed PICUs in a free-standing children's hospital. PARTICIPANTS Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians. MEASUREMENTS AND MAIN RESULTS Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = -4.34; p = 0.0003), controlling for previously mentioned factors in the model. CONCLUSIONS Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.
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Affiliation(s)
- Tessie W October
- 1Department of Critical Care Medicine, Children's National Health Systems, Washington, DC. 2Department of Pediatrics, George Washington University School of Medicine, Washington, DC. 3Department of Nursing Research and Quality Outcomes, Children's National Health Systems, Washington, DC. 4Center for Translational Science, Department of Pediatrics, Children's National Health Systems, Washington, DC. 5Department of Epidemiology and Biostatistics, George Washington University School of Medicine, Washington, DC. 6Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Gigon F, Merlani P, Ricou B. Advance Directives and Communication Skills of Prehospital Physicians Involved in the Care of Cardiovascular Patients. Medicine (Baltimore) 2015; 94:e2112. [PMID: 26656337 PMCID: PMC5008482 DOI: 10.1097/md.0000000000002112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD with cardiovascular patients. The majority would prefer that physicians of another specialty, most frequently general practitioners, initiate conversation about AD. In order to increase prehospital AD incidence, efforts must be centered on improving practitioners' communication skills regarding death, by providing trainings to allow physicians to feel more at ease when speaking about end-of-life issues.
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Affiliation(s)
- Fabienne Gigon
- From the Intensive Care Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (FG, BR) and Intensive Care Medicine, Ospedale Regionale di Lugano, Lugano, Switzerland (PM)
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Long AC, Muni S, Treece PD, Engelberg RA, Nielsen EL, Fitzpatrick AL, Curtis JR. Time to Death after Terminal Withdrawal of Mechanical Ventilation: Specific Respiratory and Physiologic Parameters May Inform Physician Predictions. J Palliat Med 2015; 18:1040-7. [PMID: 26555010 DOI: 10.1089/jpm.2015.0115] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Discussions about withdrawal of life-sustaining therapies often include family members of critically ill patients. These conversations should address essential components of the dying process, including expected time to death after withdrawal. OBJECTIVES The study objective was to aid physician communication about the dying process by identifying predictors of time to death after terminal withdrawal of mechanical ventilation. METHODS We conducted an observational analysis from a single-center, before-after evaluation of an intervention to improve palliative care. We studied 330 patients who died after terminal withdrawal of mechanical ventilation. Predictors included patient demographics, laboratory, respiratory, and physiologic variables, and medication use. RESULTS The median time to death for the entire cohort was 0.58 hours (interquartile range (IQR) 0.22-2.25 hours) after withdrawal of mechanical ventilation. Using Cox regression, independent predictors of shorter time to death included higher positive end-expiratory pressure (per 1 cm H2O hazard ratio [HR], 1.07; 95% CI 1.04-1.11); higher static pressure (per 1 cm H2O HR, 1.03; 95% CI 1.01-1.04); extubation prior to death (HR, 1.41; 95% CI 1.06-1.86); and presence of diabetes (HR, 1.75; 95% CI 1.25-2.44). Higher noninvasive mean arterial pressure predicted longer time to death (per 1 mmHg HR, 0.98; 95% CI 0.97-0.99). CONCLUSIONS Comorbid illness and key respiratory and physiologic parameters may inform physician predictions of time to death after withdrawal of mechanical ventilation. An understanding of the predictors of time to death may facilitate discussions with family members of dying patients and improve communication about end-of-life care.
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Affiliation(s)
- Ann C Long
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Sarah Muni
- 2 EvergreenHealth Pulmonary Care , Kirkland, Washington
| | - Patsy D Treece
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Elizabeth L Nielsen
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Annette L Fitzpatrick
- 3 Department of Family Medicine, University of Washington , Seattle, Washington.,4 Department of Epidemiology, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
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28
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Grady PA, Gough LL. Nursing Science: Claiming the Future. J Nurs Scholarsh 2015; 47:512-21. [DOI: 10.1111/jnu.12170] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Patricia A. Grady
- Director, National Institute of Nursing Research; National Institutes of Health; Bethesda MD USA
| | - Lisa Lucio Gough
- Health Science Policy Analyst, National Institute of Nursing Research; National Institutes of Health; Bethesda MD USA
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Hutchison PJ. POINT: Do Physicians Have a Responsibility to Provide Recommendations Regarding Goals of Care to Surrogates of Dying Patients in the ICU? Yes. Chest 2015; 147:1453-5. [DOI: 10.1378/chest.15-0273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Armstrong MH, Poku JK, Burkle CM. Medical futility and nonbeneficial interventions: an algorithm to aid clinicians. Mayo Clin Proc 2014; 89:1599-607. [PMID: 25441398 DOI: 10.1016/j.mayocp.2014.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 08/18/2014] [Accepted: 08/29/2014] [Indexed: 11/23/2022]
Affiliation(s)
- Matthew H Armstrong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Joseph K Poku
- Department of Anesthesiology, University of Rochester Medical Center, Rochester, MN
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Holms N, Milligan S, Kydd A. A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. Int J Palliat Nurs 2014; 20:549-56. [PMID: 25426882 DOI: 10.12968/ijpn.2014.20.11.549] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Natalie Holms
- NHS Lanarkshire; University of the West of Scotland, Scotland, United Kingdom
| | - Stuart Milligan
- NHS Lanarkshire; University of the West of Scotland, Scotland, United Kingdom
| | - Angela Kydd
- NHS Lanarkshire; University of the West of Scotland, Scotland, United Kingdom
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Howell AA, Nielsen EL, Turner AM, Curtis JR, Engelberg RA. Clinicians' perceptions of the usefulness of a communication facilitator in the intensive care unit. Am J Crit Care 2014; 23:380-6. [PMID: 25179033 DOI: 10.4037/ajcc2014517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Despite its documented importance, communication between clinicians and patients' families in the intensive care unit often fails to meet families' needs, and interventions to improve communication are needed. Use of a communication facilitator-an additional staff member-to improve communication between clinicians and patients' families is the focus of an ongoing randomized trial. The clinical team's acceptance of the communication facilitator as an integral part of the team is important. OBJECTIVES To explore clinicians' perceptions of the usefulness of a communication facilitator in the intensive care unit. METHODS Fourteen semistructured qualitative interviews to assess perspectives of physicians, nurses, and social workers who had experience with the communication facilitator intervention on the intervention and the role of the facilitator. Methods based on grounded theory were used to analyze the data. RESULTS Clinicians perceived facilitators as (1) facilitating communication between patients' families and clinicians, (2) providing practical and emotional support for patients' families, and (3) providing practical and emotional support for clinicians. Clinicians were enthusiastic about the communication facilitator but concerned about overlapping or conflicting roles. CONCLUSIONS Clinicians in the intensive care unit saw the facilitator intervention as enhancing communication and supporting both patients' families and clinicians. They also identified the importance of the facilitator within the interdisciplinary team. Negative perceptions about the use of a facilitator should be addressed before the intervention is implemented, in order to ensure its effectiveness.
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Affiliation(s)
- Abigail A Howell
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Elizabeth L Nielsen
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Anne M Turner
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - J Randall Curtis
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Ruth A Engelberg
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle.
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Hurdle V, Ouellet JF, Dixon E, Howard TJ, Lillemoe KD, Vollmer CM, Sutherland FR, Ball CG. Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey. Can J Surg 2014; 57:E69-74. [PMID: 24869619 DOI: 10.1503/cjs.011213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.
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Affiliation(s)
- Valerie Hurdle
- The Department of Surgery, University of Calgary, Calgary, Alta
| | | | - Elijah Dixon
- The Department of Surgery, University of Calgary, Calgary, Alta
| | - Thomas J Howard
- The Department of Surgery, Community Health Network, Indianapolis, Ind
| | - Keith D Lillemoe
- The Department of Surgery, Harvard University, Massachusetts General Hospital, Boston, Mass
| | - Charles M Vollmer
- The Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Chad G Ball
- The Department of Surgery, University of Calgary, Calgary, Alta
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Higginson IJ, Koffman J, Hopkins P, Prentice W, Burman R, Leonard S, Rumble C, Noble J, Dampier O, Bernal W, Hall S, Morgan M, Shipman C. Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty. BMC Med 2013; 11:213. [PMID: 24083470 PMCID: PMC3850793 DOI: 10.1186/1741-7015-11-213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult. METHODS Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher's exact test (for non-normally distributed characteristics) and the Mann-Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded. RESULTS PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann-Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not. CONCLUSIONS PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, School of Medicine, Bessemer Road, Denmark Hill, London SE5 9PJ, UK.
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Dev R, Coulson L, Del Fabbro E, Palla SL, Yennurajalingam S, Rhondali W, Bruera E. A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions. J Pain Symptom Manage 2013; 46:536-45. [PMID: 23507128 DOI: 10.1016/j.jpainsymman.2012.10.280] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 10/03/2012] [Accepted: 10/17/2012] [Indexed: 02/03/2023]
Abstract
CONTEXT Limited research has taken place examining family conferences (FCs) with patients with advanced cancer and their caregivers in the palliative care setting. OBJECTIVES To characterize the FCs involving cancer patients in a palliative care unit at a comprehensive cancer center and examine the effects of patient participation on emotional expression by the participants and end-of-life discussions. METHODS A data collection sheet was completed immediately after 140 consecutive FCs that documented the number of participants, caregiver demographics, expressions of emotional distress, dissatisfaction with care, and the topics discussed. Patient demographics and discharge disposition also were collected. RESULTS Seventy (50%) patients were female, 64 (46%) were white, and 127 (91%) had solid tumors. Median age of patients was 59 years. Patients participated in 68 of 140 FCs (49%). Primary caregivers (n = 140) were female (66%), white (49%), and the spouse/partner (59%). Patients verbalized distress frequently (73%). Primary caregivers' verbal expression of emotional distress was high (82%) but not significantly affected by patient presence (82% vs. 82%, P = 0.936). Verbal expressions of emotional distress by other family members were more common when patients were absent (87%) than when present (73%), P = 0.037. Questions concerning advance directives (21%), symptoms anticipated at death (31%), and caregiver well-being (29%) were infrequent. Patient presence was significantly associated with increased discussions regarding goals of care (P = 0.009) and decreased communication concerning prognosis (P = 0.004) and what symptoms dying patients may experience (P < 0.001). CONCLUSION There was a high frequency of expression of emotional distress by patients and family members in FCs. Patient participation was significantly associated with decreased verbal emotional expression by family members but not the primary caregiver and was associated with fewer discussions regarding prognosis and what dying patients may experience.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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Huynh TN, Walling AM, Le TX, Kleerup EC, Liu H, Wenger NS. Factors associated with palliative withdrawal of mechanical ventilation and time to death after withdrawal. J Palliat Med 2013; 16:1368-74. [PMID: 24083651 DOI: 10.1089/jpm.2013.0142] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In imminently dying patients, mechanical ventilation withdrawal is often a comfort measure and avoids prolonging the dying process. OBJECTIVE The aim of the study was to identify factors associated with palliative withdrawal of mechanical ventilation and time to death after extubation. METHODS Logistic regression models were used to identify factors associated with palliative withdrawal of mechanical ventilation. Cox proportional hazards models were used to determine factors associated with time to death after extubation. We retrospectively evaluated 322 patients who died on mechanical ventilation or after palliative ventilator withdrawal at a single tertiary care center. RESULTS Of the 322 ventilated deaths, 159 patients had palliative withdrawal of mechanical ventilation and 163 patients died on the ventilator. Clinical service was associated with palliative withdrawal of mechanical ventilation: Patients withdrawn from the ventilator were less likely to be on the surgery service and more likely to be on the neurology/neurosurgical service. The median time to death was 0.9 hours (range 0-165 hours). Fraction of inspired oxygen (FIO2) greater than 70% (hazard ratio [HR] 1.92, 95% confidence interval [CI ]1.24-2.99) and a requirement for vasopressors (HR 2.06, 95% CI 1.38-3.09) were associated with shorter time to death. Being on the neurology/neurosurgical service at the time of ventilator withdrawal was associated with a longer time to death (HR 0.60, 95% CI 0.39-0.92). CONCLUSIONS Palliative withdrawal of mechanical ventilation was performed in only half of dying mechanically ventilated patients. Because clinical service rather than physiologic parameters are associated with withdrawal, targeted interventions may improve withdrawal decisions. Considering FIO2 and vasopressor requirements may facilitate counseling families about anticipated time to death.
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Affiliation(s)
- Thanh N Huynh
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California , Los Angeles
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Komura K, Yamagishi A, Akizuki N, Kawagoe S, Kato M, Morita T, Eguchi K. Patient-perceived usefulness and practical obstacles of patient-held records for cancer patients in Japan: OPTIM study. Palliat Med 2013; 27:179-84. [PMID: 22179597 DOI: 10.1177/0269216311431758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although the use of a patient-held record (PHR) for cancer patients has been introduced in many settings, little is known about the role of the PHR in palliative care settings and use in Asian cultures. AIM This study investigated the patient-perceived usefulness and practical obstacles of using the PHR specifically designed for palliative care patients. DESIGN This study adopted a qualitative design based on semi-structured interviews and content analysis. SETTING/PARTICIPANTS Fifty cancer patients were recruited from two regions in Japan. They used the PHR for more than three months, and then were asked to participate in a face-to-face interview. RESULTS The content analysis revealed the following patient-perceived usefulness of the PHR: (1) increase in patient-staff communication; (2) increase in patient-family communication; (3) increase in patient-patient communication; (4) increase in understanding of medical conditions and treatments; and (5) facilitating end-of-life care discussion. The practical obstacles to using the PHR were also indicated: (1) the lack of adequate instruction about the role of the PHR; (2) undervaluing the role of the PHR and sharing information by medical professionals; (3) patients' unwillingness to participate in decision making; (4) concerns about privacy; (5) burdensome nature of self-reporting; and (6) patients' preference for their own ways of recording. CONCLUSIONS The PHR can be helpful in facilitating communication, understanding medical conditions and treatments, and facilitating end-of-life care discussion; however, for wide-spread implementation, resolving the obstacles related to both patients and health-care professionals is required.
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Affiliation(s)
- Kazue Komura
- Department of Clinical Thanatology and Geriatric Behavioral Science, Graduate School of Human Sciences, Osaka University, Osaka, Japan.
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Clerici CA, Ferrari A, Veneroni L, Casiraghi G, Giacon B, Armiraglio M, Massimino M. At Least we can Send Some Flowers…. TUMORI JOURNAL 2012. [DOI: 10.1177/030089161209800527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Cancer may demand lengthy treatment and the emotional attachment between care providers and the patient may become intense, especially when the latter is a child. If patients die, their families and the care-providing staff need help to cope with the loss. Short communication We describe a procedure in use at the Istituto Nazionale Tumori in Milan for taking leave of families whose children die. This practice is based on simply sending flowers to families who have lost their child, and was started after an emotionally very demanding case. Conclusion Our sending flowers with a handwritten condolence letter is a simple gesture that seems to have helped both the patients' families and the members of our care-providing team in the process of mourning.
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Affiliation(s)
- Carlo Alfredo Clerici
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
- Psychology Section, Department of Biomolecular Sciences and Biotechnologies, Faculty of Medicine, University of Milan, Milan
- SSD Psicologia Clinica, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Laura Veneroni
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
- Psychology Section, Department of Biomolecular Sciences and Biotechnologies, Faculty of Medicine, University of Milan, Milan
| | - Giovanna Casiraghi
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Barbara Giacon
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | | | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan
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Adams J, Bailey DE, Anderson RA, Galanos AN. Adaptive leadership: a novel approach for family decision making. J Palliat Med 2012; 16:326-9. [PMID: 22663140 DOI: 10.1089/jpm.2011.0406] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Family members of intensive care unit (ICU) patients want to be involved in decision making, but they may not be best served by being placed in the position of having to solve problems for which they lack knowledge and skills. This case report presents an exemplar family meeting in the ICU led by a palliative care specialist, with discussion about the strategies used to improve the capacity of the family to make a decision consistent with the patient's goals. These strategies are presented through the lens of Adaptive Leadership.
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Affiliation(s)
- Judith Adams
- School of Nursing, Duke University, Durham, North Carolina 27710, USA.
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41
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Gutierrez KM. Prognostic categories and timing of negative prognostic communication from critical care physicians to family members at end-of-life in an intensive care unit. Nurs Inq 2012; 20:232-44. [PMID: 22672664 DOI: 10.1111/j.1440-1800.2012.00604.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Negative prognostic communication is often delayed in intensive care units, which limits time for families to prepare for end-of-life. This descriptive study, informed by ethnographic methods, was focused on exploring critical care physician communication of negative prognoses to families and identifying timing influences. Prognostic communication of critical care physicians to nurses and family members was observed and physicians and family members were interviewed. Physician perception of prognostic certainty, based on an accumulation of empirical data, and the perceived need for decision-making, drove the timing of prognostic communication, rather than family needs. Although prognoses were initially identified using intuitive knowledge for patients in one of the six identified prognostic categories, utilizing decision-making to drive prognostic communication resulted in delayed prognostic communication to families until end-of-life (EOL) decisions could be justified with empirical data. Providers will better meet the needs of families who desire earlier prognostic information by separating prognostic communication from decision-making and communicating the possibility of a poor prognosis based on intuitive knowledge, while acknowledging the uncertainty inherent in prognostication. This sets the stage for later prognostic discussions focused on EOL decisions, including limiting or withdrawing treatment, which can be timed when empirical data substantiate intuitive prognoses. This allows additional time for families to anticipate and prepare for end-of-life decision-making.
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Affiliation(s)
- Karen M Gutierrez
- Metropolitan State University, St. Paul, Minneapolis, MN 55331, USA.
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Understanding Goals of Care Statements and Preferences among Patients and Their Surrogates in the Medical ICU. J Hosp Palliat Nurs 2012; 14:126-132. [PMID: 22423214 DOI: 10.1097/njh.0b013e3182389dd2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND: Treatment decisions should be based on patients' goals of care to provide an ethical, patient-centered framework for decision-making. OBJECTIVES: The purpose of this study is to improve our understanding about how patients' and surrogates' goals of care are communicated and interpreted in an MICU. METHODS: One hundred patients admitted to an MICU, or their surrogates, responded to an open-ended question about goals of care for their hospitalization followed by a closed-ended question regarding their most important goal of care. Investigators interpreted participants' open-ended responses and compared these interpretations with participants' closed-ended, most-important-goal selections. RESULTS: Investigators' interpretations of participants' open-ended goals of care responses matched participants' closed-ended most important goal of care in only 28 of 100 cases. However, there was good inter-rater reliability between investigators in their interpretation of participants' open-ended responses, with agreement in 78 of 100 cases. CONCLUSIONS: Clinicians should be cautious in interpreting patients' or surrogates' responses to open-ended questions about goals of care. A shared understanding of goals of care may be facilitated by alternating open-ended and closed-ended questions to clarify patients' or surrogates' responses.
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Billings JA. The end-of-life family meeting in intensive care part I: Indications, outcomes, and family needs. J Palliat Med 2011; 14:1042-50. [PMID: 21830914 DOI: 10.1089/jpm.2011.0038] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This is a three-part article that reviews the literature on end-of-life family meetings in intensive care, focused on situations when the patient cannot participate. Family meetings in end-of-life care, especially when conducted prophylactically or proactively, have been shown to be effective procedures for improving family and staff satisfaction and even reducing resource utilization. The first part of the article outlines the family needs that should be addressed in such meetings, including clinician availability, consistent information sharing (especially of prognosis), empathic communication and support, facilitation of bereavement, and trust. The second part addresses family-centered, shared decision making and sources of conflict, as well as related communication and negotiation skills and how to end the meeting. Families and clinicians differ in 1) their understanding of the patient's condition and prognosis; 2) the emotional impact of the illness, particularly the personal meaning of pursuing recovery or limiting supports; and 3) their views of how to make decisions about life-prolonging treatments. The final part draws on the previous two sections to present a structured format and guide for communication skills in conflictual meetings. Ten steps for a humane and effective meeting are suggested, illustrated with sample conversations.
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Affiliation(s)
- J Andrew Billings
- Harvard Medical School Center for Palliative Care, Boston, Massachusetts, USA
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44
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The impact of country and culture on end-of-life care for injured patients: results from an international survey. ACTA ACUST UNITED AC 2011; 69:1323-33; discussion 1333-4. [PMID: 21045742 DOI: 10.1097/ta.0b013e3181f66878] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures. METHODS A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma. RESULTS A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries. CONCLUSIONS In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).
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Festic E, Wilson ME, Gajic O, Divertie GD, Rabatin JT. Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit. J Intensive Care Med 2011; 27:45-54. [PMID: 21257636 DOI: 10.1177/0885066610393465] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CONTEXT The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. OBJECTIVE To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. DESIGN Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. SETTING Single tertiary care academic medical institution. RESULTS A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. CONCLUSIONS Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.
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Affiliation(s)
- Emir Festic
- Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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46
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Jacobsen J, Robinson E, Jackson VA, Meigs JB, Billings JA. Development of a cognitive model for advance care planning discussions: results from a quality improvement initiative. J Palliat Med 2011; 14:331-6. [PMID: 21247300 DOI: 10.1089/jpm.2010.0383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Residents struggle with advance care planning (ACP) discussions in the inpatient setting, and may not be aware of newer models for ACP that stress the importance of giving prognostic information and making a recommendation about cardiopulmonary resuscitation to patients and families. METHODS A controlled study of a cognitive model for ACP embedded in a quality improvement (QI) project. RESULTS In the setting of a QI project for medical residents and interdisciplinary staff, we developed and implemented a cognitive model of ACP discussions that involved two types of meetings for patients: (1) information-sharing meetings for seriously ill but clinically stable patients and (2) decision-making meetings for clinically unstable patients. Patients on the intervention floor were significantly more likely to have a discussion about goals of care (33.8%) than patients on the control floor (21.2%, p = < 0.001) and significantly more likely to have a limitation of life-sustaining treatment upon discharge (19.1% vs. 13.9%, p = 0.04). CONCLUSIONS For both residents and interdisciplinary staff, application of a cognitive model that clearly defines goals and expectations for ACP discussions prior to meeting with patients and families improves rates of ACP discussions.
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Affiliation(s)
- Juliet Jacobsen
- Palliative Care Service, Massachusetts General Hospital , Boston, MA 02114, USA.
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47
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Conn R, Berry PA. The decision to engage in end-of-life discussions: a structured approach for doctors in training. Clin Med (Lond) 2010; 10:468-71. [PMID: 21117379 PMCID: PMC4952408 DOI: 10.7861/clinmedicine.10-5-468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Engaging in end-of-life discussions is a major source of anxiety for doctors in training. The authors propose the use of a decision-making model to assist trainees and their clinical supervisors in such situations. Divided into' 'patient-centred' and 'physician-centred' components, the model ensures that the following aspects are analysed: patient and family safety, patient and family choice, physician competence and physician comfort. A real but historical end-of-life scenario is presented to a foundation year 1 doctor, and the particular risks of engaging in a discussion are subsequently clarified with reference to each of the model's components.
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Chipman JG, Webb TP, Shabahang M, Heller SF, vanCamp JM, Waer AL, Luxenberg MG, Christenson M, Schmitz CC. A multi-institutional study of the Family Conference Objective Structured Clinical Exam: a reliable assessment of professional communication. Am J Surg 2010; 201:492-7. [PMID: 20850709 DOI: 10.1016/j.amjsurg.2010.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 02/09/2010] [Accepted: 02/16/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND To test the value of a simulated Family Conference Objective Structured Clinical Exam (OSCE) for resident assessment purposes, we examined the generalizability and construct validity of its scores in a multi-institutional study. METHODS Thirty-four first-year (PG1) and 27 third-year (PG3) surgery residents (n = 61) from 6 training programs were tested. The OSCE consisted of 2 cases (End-of-Life [EOL] and Disclosure of Complications [DOC]). At each program, 2 clinicians and 2 standardized family members rated residents using case-specific tools. Performance was measured as the percentage of possible score obtained. We examined the generalizability of scores for each case separately. To assess construct validity, we compared PG1 with PG3 performance using repeated measures multivariate analysis of variance (MANOVA). RESULTS The relative G-coefficient for EOL was .890. For DOC, the relative G-coefficient was .716. There were no significant performance differences between PG1 and PG3 residents. CONCLUSIONS This OSCE provides reliable assessments suitable for formative evaluation of residents' interpersonal communication skills and professionalism.
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Affiliation(s)
- Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, 55455, USA.
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Levin TT, Moreno B, Silvester W, Kissane DW. End-of-life communication in the intensive care unit. Gen Hosp Psychiatry 2010; 32:433-42. [PMID: 20633749 DOI: 10.1016/j.genhosppsych.2010.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/21/2010] [Accepted: 04/22/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication. DESIGN For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers. RESULTS Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency. CONCLUSIONS Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.
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Affiliation(s)
- Tomer T Levin
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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50
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Cooke CR, Hotchkin DL, Engelberg RA, Rubinson L, Curtis JR. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest 2010; 138:289-97. [PMID: 20363840 DOI: 10.1378/chest.10-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation. METHODS We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients' charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes. RESULTS The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women. The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours). Using Cox regression, the independent predictors of a shorter time to death were nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35), number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19), vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56). Predictors of longer time to death were older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and female sex (HR, 0.86; 95% CI, 0.77-0.97). CONCLUSIONS Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.
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Affiliation(s)
- Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, University of Michigan, 6 Ann Arbor, MI 48109-5604, USA.
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