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Lehto HR, Jain N, Manning KA, Lakin JR, Sheu C, Reich AJ, Desai AS, Sciacca KR, Lindvall CJ, Tulsky JA, Bernacki RE. Timing and content of serious illness conversations for patients with advanced heart failure in a specialty-aligned palliative care service. Heart Lung 2024; 69:1-10. [PMID: 39265432 DOI: 10.1016/j.hrtlng.2024.09.004] [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: 05/19/2024] [Revised: 08/24/2024] [Accepted: 09/03/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Patients with advanced heart failure (AHF) desire communication around values and goals prior to treatment decisions. OBJECTIVES To evaluate the timing and content of the first serious illness communication (SI conversation) for patients with AHF after referral to a specialist palliative care (PC) team (HeartPal). METHODS In this retrospective cohort study, we used electronic health records to identify patients referred to HeartPal and their first SI conversations at a tertiary care hospital between October 2018 and September 2021. We used natural language processing and predetermined codes to quantify prevalence of prior goals of care conversations by the cardiology team within six months preceding the HeartPal consultation and the prevalence of hopes, fears, and seven conversation content codes. Consecutive SI conversations and patient outcomes were followed until March 2022. RESULTS Of 468 patients (mean age: 64 years, 72 % male, 66 % referred for goals of care conversation), 25.2 % had prior documented goals of care conversations preceding the HeartPal consultation. During the study period, 206 (44.0 %) patients died (median time from initial SI conversation to death: 65 days, IQR 206) and 43.2 % engaged in multiple SI conversations before death. SI conversation analysis (n = 324) revealed that patients hoped to "be at home" (74.1 %, n = 240), "be independent" (65.7 %, n = 213) and "live as long as possible" (53.4 %, n = 173). Conversation content included goals of care (83.0 %), strengths (83.0 %), decision-making (79.3 %), spirituality (71.0 %), coping (52.2 %), and prognostic communication (43.5 %). CONCLUSION Specialist PC service provides documentation of goals and values and offers longitudinal follow-up for patients with AHF.
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Affiliation(s)
- Hanna-Riikka Lehto
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Katharine A Manning
- Division of Cardiovascular Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, United States; Dartmouth Geisel School of Medicine, Lebanon, NH, United States
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Christina Sheu
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States; The Center for Geriatric Surgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Amanda J Reich
- Harvard Medical School, Boston, MA, United States; The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States
| | - Akshay S Desai
- Harvard Medical School, Boston, MA, United States; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Kate R Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Charlotta J Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States
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Bell SR, Karlin DM, Phung PG, Pietras CJ, Stepanyan KD. Serious Illness Communication Tool for Palliative Care Fellows: Development, Implementation, and Lessons Learned. Am J Hosp Palliat Care 2024:10499091241259491. [PMID: 38867612 DOI: 10.1177/10499091241259491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
Introduction: Learning expert communication skills is a core educational goal within palliative care training, yet there are few communication-based educational tools specifically designed for specialty-trained palliative care providers. Objective: To develop and implement a tool to facilitate effective learning of serious illness communication for hospice and palliative medicine fellows. Methods: A novel formative assessment tool was developed within the UCLA Palliative Care Fellowship program, and utilized throughout the academic year on a weekly basis. Focus groups were held for fellows and faculty separately at the end of the academic year in order to gain insight into the experience and effectiveness of the tool. Focus group transcripts were analyzed through thematic analysis. Results: There was a 47% participation rate in the focus groups (n = 7). Qualitative analysis demonstrated positive impact of the tool in identifying learning goals, improving quality of feedback, and in standardizing language around advanced communication skills, with most value in the first half of the fellowship year. Some aspects of the tool were found to increase feedback anxiety, including the competency scoring component, frequency of use, and utilization with individual patient encounters. Conclusion: This novel communication tool provides an important addition to serious illness communication training of specialist palliative care providers, in creating a shared mental model for naming and organizing skills, as well as generating specific high quality learning goals and feedback. Preliminary feedback from our pilot implementation phase provided important information about how to refine the tool and remove components that unnecessarily added to feedback anxiety.
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Amouzegar A, Haig S, Kahn AM, Tawbi HA, Jones JA, Goldberg SB. Navigating the Complexities of Brain Metastases Management. Am Soc Clin Oncol Educ Book 2024; 44:e433694. [PMID: 38781565 DOI: 10.1200/edbk_433694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.
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Affiliation(s)
- Afsaneh Amouzegar
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon Haig
- Lake Erie College of Osteopathic Medicine, Greensburg, PA
| | - Adriana M Kahn
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joshua A Jones
- Department of Oncology, Division of Radiation Oncology and Division of Palliative Medicine, Rochester Regional Health System, Rochester, NY
| | - Sarah B Goldberg
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
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Baxter R, Pusa S, Andersson S, Sandgren A. Perils and payoffs for patients in serious illness conversations as described by physicians: a qualitative study. BMJ Open Qual 2024; 13:e002734. [PMID: 38782485 PMCID: PMC11116881 DOI: 10.1136/bmjoq-2023-002734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The Serious Illness Care Programme was developed to promote more, better and earlier serious illness conversations. Conversations about goals and values are associated with improved experiences and outcomes for seriously ill patients. Clinicians' attitudes and beliefs are thought to influence the uptake and performance of serious illness conversations, yet little is known about how clinicians perceive the impact of these conversations on patients. This study aimed to explore physicians' perceptions regarding the impact of serious illness conversations for patients. METHODS The Serious Illness Care Programme was implemented as a quality improvement project in two hospitals in Southern Sweden. Focus group evaluation discussions were conducted with 14 physicians and inductive thematic analysis was undertaken. RESULTS The results revealed that physicians considered potential perils and optimised potential payoffs for patients when engaging in serious illness conversations. Potential perils encompassed inappropriate timing, damaging emotions and shattering hopes. Potential payoffs included reflection time, secure space, and united understandings. CONCLUSIONS Physicians depicted a balance in evaluating the perils and payoffs of serious illness conversations for patients and recognised the interrelation of these possibilities through continual assessment and adjustment.
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Affiliation(s)
- Rebecca Baxter
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Susanna Pusa
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Anna Sandgren
- Department of Health and Caring Sciences, Linneaus University, Växjö, Sweden
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Singh N, Giannitrapani KF, Gamboa RC, O’Hanlon CE, Fereydooni S, Holdsworth LM, Lindvall C, Walling AM, Lorenz KA. What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic. Am J Hosp Palliat Care 2024; 41:558-567. [PMID: 37390466 PMCID: PMC10315453 DOI: 10.1177/10499091231187351] [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] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Interpersonal communication is a cornerstone of patient-centered care. We aimed to identify what patients with cancer and caregivers may want from communication during a public health crisis. METHODS We interviewed 15 patients (8 Veteran, 7 non-Veteran) and caregivers from regionally, racially, and ethnically diverse backgrounds across the US about serious illness care and quality of care during the COVID-19 pandemic Using an iterative, inductive and deductive process, 2 coders analyzed content associated with the code "Communication," which appeared 71 times, and identified 5 themes. RESULTS Participants identified as White (10), Latino/a (3), Asian (1), and Black (1). (1) Help patients and caregivers prepare for care during crisis by communicating medical information directly and proactively. (2) Explain how a crisis might influence medical recommendations and impact on recovery from illness. (3) Use key messengers to improve communication between primary teams, patients, and caregivers. (4) Include caregivers and families in communication when they cannot be physically present. (5) Foster bidirectional communication with patients and families to engage them in shared decision-making during a vulnerable time. CONCLUSION Communication is critical during a public health crisis yet overwhelmed clinicians may not be able to communicate effectively. Communicating with caregivers and family, transparent and timely communication, ensuring diverse providers are on the same page, and effective listening are known gaps even before the COVID-19 pandemic. Clinicians may need quick interventions, like education about goals of care, to remind them about what seriously ill patients and their caregivers want from communication and offer patient-centered care during crises.
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Affiliation(s)
- Nainwant Singh
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Karleen F. Giannitrapani
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Raziel C. Gamboa
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | | | | | | | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Karl A. Lorenz
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
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Horecki P, Deming J, Lagunas M, Brustad R, Okuno S, Manz J, Christensen S, Suhail Z. Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools. J Palliat Med 2024; 27:658-662. [PMID: 38364111 DOI: 10.1089/jpm.2023.0580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.
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Affiliation(s)
- Patty Horecki
- Department of Experience Training, Education, and Coaching, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - James Deming
- Department of Clinical Medicine, Palliative Care, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Meg Lagunas
- Department of Nursing, University of Wisconsin, Eau Claire, Eau Claire, Wisconsin, USA
| | - Rebecca Brustad
- Department of Quality, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott Okuno
- Department of Oncology, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - James Manz
- Department of Spine, Neurological Surgery, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Sue Christensen
- Administration, Mayo Clinic Health System, NWWI, Eau Claire, Wisconsin, USA
| | - Zoha Suhail
- Department of Nursing, University of Wisconsin, Eau Claire, Eau Claire, Wisconsin, USA
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Pusa S, Baxter R, Andersson S, Fromme EK, Paladino J, Sandgren A. Core Competencies for Serious Illness Conversations: An Integrative Systematic Review. J Palliat Care 2024:8258597241245022. [PMID: 38557369 DOI: 10.1177/08258597241245022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.
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Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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Hui D, Huang YT, Andersen C, Cassel B, Nortje N, George M, Bruera E. Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis. Cancers (Basel) 2024; 16:1316. [PMID: 38610994 PMCID: PMC11010830 DOI: 10.3390/cancers16071316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.
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Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Yu-Ting Huang
- Cost Management and Decision Support, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Clark Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Brian Cassel
- Hematology/Oncology & Palliative Care, Virginia Commonwealth University, Richmond, VA 22043, USA;
| | - Nico Nortje
- Section of Integrated Ethics, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- Department of Dietetics and Nutrition, University of the Western Cape, Bellville 7535, South Africa
| | - Marina George
- Department of Hospital Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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Adeyemi O, Walker L, Bermudez E, Cuthel AM, Zhao N, Siman N, Goldfeld K, Brody AA, Bouillon-Minois JB, DiMaggio C, Chodosh J, Grudzen CR. Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis. J Emerg Nurs 2024; 50:225-242. [PMID: 37966418 PMCID: PMC10939973 DOI: 10.1016/j.jen.2023.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 07/27/2023] [Accepted: 09/06/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.
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Affiliation(s)
- Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | | | | | - Allison M. Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Nicole Zhao
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook NY
| | - Nina Siman
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
| | - Keith Goldfeld
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York, USA
- Emergency Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles DiMaggio
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
| | - Joshua Chodosh
- New York University Grossman School of Medicine, Department of Population Health, New York, New York, USA
- New York University Grossman School of Medicine, Department of Medicine, New York, New York, USA
| | - Corita R. Grudzen
- New York University Grossman School of Medicine, Department of Surgery, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care 2024:spcare-2023-004163. [PMID: 37369576 DOI: 10.1136/spcare-2023-004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide. AIM This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG. DESIGN Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis. RESULTS A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care. CONCLUSIONS Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.
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Affiliation(s)
- Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
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Viñolas N, Mezquita L, Corral J, Cobo M, Gil-Moncayo F, Paz-Ares L, Remon J, Rodríguez M, Ruano-Raviña A, Conde E, Majem M, Garrido P, Felip E, Isla D, de Castro J. The role of sex and gender in the diagnosis and treatment of lung cancer: the 6th ICAPEM Annual Symposium. Clin Transl Oncol 2024; 26:352-362. [PMID: 37490262 DOI: 10.1007/s12094-023-03262-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023]
Abstract
The incidence and mortality of lung cancer in women are rising, with both increasing by 124% between 2003 and 2019. The main risk factor for lung cancer is tobacco use, but indoor radon gas exposure is one of the leading causes in nonsmokers. The most recent evidence demonstrates that multiple factors can make women more susceptible to harm from these risk factors or carcinogens. For this consensus statement, the Association for Lung Cancer Research in Women (ICAPEM) invited a group of lung cancer experts to perform a detailed gender-based analysis of lung cancer. Clinically, female patients have different lung cancer profiles, and most actionable driver alterations are more prevalent in women, particularly in never-smokers. Additionally, the impact of certain therapies seems to be different. In the future, it will be necessary to carry out specific studies to improve the understanding of the role of certain biomarkers and gender in the prognosis and evolution of lung cancer.
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Affiliation(s)
- Nuria Viñolas
- Department of Medical Oncology, Barcelona Clinic Hospital, Translational Genomics and Targeted Therapies in Solid Tumours, IDIBAPS, C. de Villarroel, 170, 08036, Barcelona, Spain.
| | - Laura Mezquita
- Department of Medical Oncology, Barcelona Clinic Hospital, Translational Genomics and Targeted Therapies in Solid Tumours, IDIBAPS, C. de Villarroel, 170, 08036, Barcelona, Spain
| | - Jesús Corral
- Department of Medical Oncology, Jerez de la Frontera University Hospital, Cádiz, Spain
| | - Manuel Cobo
- Department of Medical Oncology, Virgen de la Victoria University Hospital, Málaga, Spain
| | - Francisco Gil-Moncayo
- Department of Psycho-Oncology, Catalan Institute of Oncology-Hospitalet, Barcelona, Spain
| | - Luis Paz-Ares
- Department of Medical Oncology, 12 de Octubre University Hospital, Madrid, Spain
| | - Jordi Remon
- Department of Medical Oncology, HM Nou Delfos Hospital, Barcelona, Spain
| | - María Rodríguez
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Alberto Ruano-Raviña
- Department of Medicine and Public Health, Santiago de Compostela University, Santiago de Compostela, Spain
| | - Esther Conde
- Pathology Department, 12 de Octubre University Hospital, Universidad Complutense de Madrid, Research Institute 12 de Octubre University Hospital (Imas12), CIBERONC, Madrid, Spain
| | - Margarita Majem
- Department of Medical Oncology, Santa Creu y Sant Pau University Hospital, Barcelona, Spain
| | - Pilar Garrido
- Department of Medical Oncology, Ramón y Cajal University Hospital, Madrid, Spain
| | - Enriqueta Felip
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Dolores Isla
- Department of Medical Oncology, Lozano Blesa University Clinical Hospital, Saragossa, Spain
| | - Javier de Castro
- Department of Medical Oncology, La Paz University Hospital, Madrid, Spain
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Ko J, Roze des Ordons A, Ballard M, Shenkier T, Simon JE, Fyles G, Lefresne S, Hawley P, Chen C, McKenzie M, Sanders J, Bernacki R. Exploring the value of structured narrative feedback within the Serious Illness Conversation-Evaluation Exercise (SIC-Ex): a qualitative analysis. BMJ Open 2024; 14:e078385. [PMID: 38286701 PMCID: PMC10826582 DOI: 10.1136/bmjopen-2023-078385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES The Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics. DESIGN Qualitative study using template analysis. SETTING Three academic cancer centres in Canada. PARTICIPANTS 7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists. INTERVENTIONS Each trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes. OUTCOME MEASURES How narrative comments aligned with elements of the CCG and SICG. RESULTS Template analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG. CONCLUSIONS Narrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.
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Affiliation(s)
- Jenny Ko
- Department of Medical Oncology, BC Cancer Agency Abbostford Centre, Abbotsford, British Columbia, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine and Division of Palliative Medicine; Department of Anesthesiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mark Ballard
- Department of Internal Medicine, Chilliwack General Hospital, Chilliwack, British Columbia, Canada
| | - Tamara Shenkier
- Department of Medical Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Jessica E Simon
- Department of Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gillian Fyles
- Pain and Symptom Management/Palliative Care Program, BC Cancer Agency Sindi Ahluwalia Hawkins Centre for the Southern Interior, Kelowna, British Columbia, Canada
| | - Shilo Lefresne
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Philippa Hawley
- Department of Palliative Care, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Charlie Chen
- Department of Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Michael McKenzie
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Justin Sanders
- Department of Palliative Care, McGill University, Montreal, Quebec, Canada
| | - Rachelle Bernacki
- Department of Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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13
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O'Donnell A, Gonyea J, Wensley T, Nizza M. High-quality patient-centered palliative care: interprofessional team members' perceptions of social workers' roles and contribution. J Interprof Care 2024; 38:1-9. [PMID: 37525994 DOI: 10.1080/13561820.2023.2238783] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 07/11/2023] [Indexed: 08/02/2023]
Abstract
A core tenet of interprofessional collaborative practice (IPCP) is that efficient and effective teams are critical for the delivery of high-quality, patient-centered care. Although palliative care has a history of excellent care, increasing demands and larger patient loads are challenging teams to adapt and strengthen team functioning in hospital settings. The purpose of this qualitative study was to better understand the IPCP contributions of advanced palliative social workers (PSWs) through the eyes of their colleagues. Twenty-four interprofessional palliative care (IPPC) team members from other professions (i.e. nurse practitioners, physicians, physician assistants) from 16 hospitals across the U.S. participated in 20-minute semi-structured interviews. The Patient-Centered Clinical Method (PCCM) was used as a conceptual model to aid in the interpretation of the data. This model illuminated the centrality of PSWs' role in building and sustaining a therapeutic alliance between the patient and the IPPC team, through assessing and promoting care that centers the patient's experience with illness, creating space to initiate, process and revisit difficult healthcare conversations and helping to modulate the pace and intensity of emotionally laden discussions. PSWs also support the therapeutic relationship with the IPPC team by providing continuity and connection across and during the hospital experience and supporting the well-being of the IPPC team. This study offers novel insights into how PSWs contribute to patient-centered IPPC and furthers the articulation of the role of PSWs in hospital settings.
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Affiliation(s)
| | - Judith Gonyea
- School of Social Work, Boston University, Boston, USA
| | | | - Megan Nizza
- School of Social Work, Boston University, Boston, USA
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14
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Andersson S, Granat L, Baxter R, Reimertz H, Modéus C, Pusa S, Sandgren A. Translation, Adaptation, and Validation of the Swedish Serious Illness Conversation Guide. J Palliat Care 2024; 39:21-28. [PMID: 37886797 PMCID: PMC10687820 DOI: 10.1177/08258597231210136] [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] [Indexed: 10/28/2023]
Abstract
Objective: To translate and adapt the Serious Illness Conversation Guide for use within the Swedish healthcare setting and examine the validity and acceptability of the Swedish Serious Illness Conversation Guide. Methods: Three rounds of cognitive interviews were conducted (T1-3); patients (T1 n = 11; T2 n = 10; T3 n = 8), family members (T1 n = 5; T2 n = 2; T3 n = 2), and healthcare professionals (T1 n = 6; T2 n = 6; T3 n = 5). The guide was iteratively adapted based on interview feedback, clinical experience, and the literature. The guide was tested on training days with physicians and nurses. Results: The Swedish Serious Illness Conversation Guide was found to be useful in supporting serious illness conversations. Clinicians reported that some questions were emotionally challenging. Explicit questions about prognosis and timing were excluded. Instead, the dual approach of "hoping for the best and preparing for the worst" was used to explore patients' thoughts about the future. Conclusions: Patients, family members, and healthcare professionals found the Swedish Serious Illness Conversation Guide to be appropriate, sensitive, and responsive to their needs. The Swedish Serious Illness Conversation Guide may facilitate a more health-promoting approach to serious illness conversations. Further research is needed to understand the impact of these conversations on person-centered and goal-concordant care.
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Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Lisa Granat
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Helene Reimertz
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Carina Modéus
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Unit of Palliative Care, Region Kronoberg, Växjö, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Linnaeus University, Växjö, Sweden
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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15
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Aasen ERHV, Søvik ML, Størdal K, Lee A. Are We on the Same Page? Exploring Pediatric Patients' Involvement With Advance Care Planning. J Pain Symptom Manage 2023; 66:e353-e363. [PMID: 37054956 DOI: 10.1016/j.jpainsymman.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND According to the UN Convention on the Rights of the Child, children have a right to be heard. This also applies to patients in pediatric palliative care (PPC). The aim of this literature review was to explore what is known about the involvement of children (<14 years of age), adolescents and young adults (AYAs) in advance care planning (ACP) in PPC. METHODS A search was conducted in PubMed including publications from January 1, 2002 until December 31, 2021. The identified citations had to report on ACP or related terms in any PPC context. RESULTS A total of n = 471 unique reports were identified. Final inclusion criteria were met by n = 21 reports, including children and AYAs with diagnoses related to oncology, neurology, HIV/AIDS and cystic fibrosis. Nine reports were from randomized controlled studies, investigating ACP methodology. The main findings were: 1) caregivers are included more often than children and adolescents in ACP, 2) some studies indicate an incongruence between AYAs and their caregivers regarding ACP and treatment preferences, 3) although the process evokes a wide range of emotions, ACP is perceived as helpful by many AYAs CONCLUSION: The majority of studies about ACP in PPC do not include children and AYAs. Whether incongruence reported in some studies between AYAs and their caregivers regarding treatment preferences could be reduced by ACP should be further explored, including the involvement of children and adolescents in ACP, and the impact of pediatric ACP on patient outcomes in PPC.
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Affiliation(s)
| | - Marte Løvaas Søvik
- Faculty of Medicine (E.R.H.V.A., M.L.S.), University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Department of Pediatric Research (K.S.), Faculty of Medicine, University of Oslo, Oslo, Norway; Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway
| | - Anja Lee
- Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway.
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16
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Nijdam TMP, Laane DWPM, Schiepers TEE, Smeeing DPJ, Kempen DHR, Willems HC, van der Velde D. The goals of care in acute setting for geriatric patients in case of a hip fracture. Eur J Trauma Emerg Surg 2023; 49:1835-1844. [PMID: 36933048 PMCID: PMC10449659 DOI: 10.1007/s00068-023-02258-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/04/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE For geriatric hip fracture patients, the decision between surgery and palliative, non-operative management is made through shared decision making (SDM). For this conversation, a physician must be familiar with the patient's goals of care (GOC). These are predominantly unknown for hip fracture patients and challenging to assess in acute setting. The objective was to explore these GOC of geriatric patients in case of a hip fracture. METHODS An expert panel gathered possible outcomes after a hip fracture, which were transformed into statements where participants indicated their relative importance on a 100-point scoring scale during interviews. These GOC were ranked using medians and deemed important if the median score was 90 or above. Patients were aged 70 years or older with a hip contusion due to similarities with the hip fracture population. Three cohorts based on frailty criteria and the diagnosis of dementia were made. RESULTS Preserving cognitive function, being with family and being with partner scored in all groups among the most important GOC. Both non-frail and frail geriatric patients scored return to pre-fracture mobility and maintaining independence among the most important GOC, where proxies of patients with a diagnosis of dementia scored not experiencing pain as the most important GOC. CONCLUSION All groups scored preserving cognitive function, being with family and being with partner among the most important GOC. The most important GOC should be discussed when a patient is presented with a hip fracture. Since patients preferences vary, a patient-centered assessment of the GOC remains essential.
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Affiliation(s)
| | | | | | | | | | - Hanna Cunera Willems
- Department of Internal Medicine and Geriatrics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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17
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Mesfin N, Wormwood J, Wiener RS, Still M, Xu CS, Palmer J, Linsky AM. Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey. J Palliat Med 2023; 26:951-959. [PMID: 36944150 PMCID: PMC10398728 DOI: 10.1089/jpm.2022.0394] [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: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.
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Affiliation(s)
- Nathan Mesfin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jolie Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- University of New Hampshire, Durham, New Hampshire, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael Still
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Chris S. Xu
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jennifer Palmer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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18
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Chi S, Kim S, Reuter M, Ponzillo K, Oliver DP, Foraker R, Heard K, Liu J, Pitzer K, White P, Moore N. Advanced Care Planning for Hospitalized Patients Following Clinician Notification of Patient Mortality by a Machine Learning Algorithm. JAMA Netw Open 2023; 6:e238795. [PMID: 37071421 PMCID: PMC10114011 DOI: 10.1001/jamanetworkopen.2023.8795] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/28/2023] [Indexed: 04/19/2023] Open
Abstract
Importance Goal-concordant care is an ongoing challenge in hospital settings. Identification of high mortality risk within 30 days may call attention to the need to have serious illness conversations, including the documentation of patient goals of care. Objective To examine goals of care discussions (GOCDs) in a community hospital setting with patients identified as having a high risk of mortality by a machine learning mortality prediction algorithm. Design, Setting, and Participants This cohort study took place at community hospitals within 1 health care system. Participants included adult patients with a high risk of 30-day mortality who were admitted to 1 of 4 hospitals between January 2 and July 15, 2021. Patient encounters of inpatients in the intervention hospital where physicians were notified of the computed high risk mortality score were compared with patient encounters of inpatients in 3 community hospitals without the intervention (ie, matched control). Intervention Physicians of patients with a high risk of mortality within 30 days received notification and were encouraged to arrange for GOCDs. Main Outcomes and Measures The primary outcome was the percentage change of documented GOCDs prior to discharge. Propensity-score matching was completed on a preintervention and postintervention period using age, sex, race, COVID-19 status, and machine learning-predicted mortality risk scores. A difference-in-difference analysis validated the results. Results Overall, 537 patients were included in this study with 201 in the preintervention period (94 in the intervention group; 104 in the control group) and 336 patients in the postintervention period. The intervention and control groups included 168 patients per group and were well-balanced in age (mean [SD], 79.3 [9.60] vs 79.6 [9.21] years; standardized mean difference [SMD], 0.03), sex (female, 85 [51%] vs 85 [51%]; SMD, 0), race (White patients, 145 [86%] vs 144 [86%]; SMD 0.006), and Charlson comorbidities (median [range], 8.00 [2.00-15.0] vs 9.00 [2.00 to 19.0]; SMD, 0.34). Patients in the intervention group from preintervention to postintervention period were associated with being 5 times more likely to have documented GOCDs (OR, 5.11 [95% CI, 1.93 to 13.42]; P = .001) by discharge compared with matched controls, and GOCD occurred significantly earlier in the hospitalization in the intervention patients as compared with matched controls (median, 4 [95% CI, 3 to 6] days vs 16 [95% CI, 15 to not applicable] days; P < .001). Similar findings were observed for Black patient and White patient subgroups. Conclusions and Relevance In this cohort study, patients whose physicians had knowledge of high-risk predictions from machine learning mortality algorithms were associated with being 5 times more likely to have documented GOCDs than matched controls. Additional external validation is needed to determine if similar interventions would be helpful at other institutions.
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Affiliation(s)
- Stephen Chi
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, Missouri
| | - Seunghwan Kim
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | | | - Debra Parker Oliver
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Randi Foraker
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Kyle Pitzer
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Patrick White
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
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19
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Oyekan AA, Lee JY, Hodges JC, Chen SR, Wilson AE, Fourman MS, Clayton EO, Njoku-Austin C, Crasto JA, Wisniewski MK, Bilderback A, Gunn SR, Levin WI, Arnold RM, Hinrichsen KL, Mensah C, Hogan MV, Hall DE. Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program. JB JS Open Access 2023; 8:JBJSOA-D-22-00107. [PMID: 37101601 PMCID: PMC10125643 DOI: 10.2106/jbjs.oa.22.00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Email for corresponding author:
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob C. Hodges
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen R. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan E. Wilson
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mitchell S. Fourman
- Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Elizabeth O. Clayton
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jared A. Crasto
- Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Scott R. Gunn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William I. Levin
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie L. Hinrichsen
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Mensah
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - MaCalus V. Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Li S, Xie J, Chen Z, Yan J, Zhao Y, Cong Y, Zhao B, Zhang H, Ge H, Ma Q, Shen N. Key elements and checklist of shared decision-making conversation on life-sustaining treatment in emergency: a multispecialty study from China. World J Emerg Med 2023; 14:380-385. [PMID: 37908803 PMCID: PMC10613793 DOI: 10.5847/wjem.j.1920-8642.2023.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/20/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Shared decision-making (SDM) has broad application in emergencies. Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice. This study is to investigate the optimal application of SDM to guide life-sustaining treatment (LST) in emergencies. METHODS This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education. Participants were identified based on their expertise in medicine, law, administration, medical education, or patient advocacy. All individual items and questions in the questionnaire were scored using a 5-point Likert scale, with responses ranging from "very unimportant" (a score of 1) to "extremely important" (a score of 5). The percentages of the responses that had scores of 4-5 on the 5-point Likert scale were calculated. A Kendall's W coefficient was calculated to evaluate the consensus of experts. RESULTS A two-level framework consisting of 4 domains and 22 items as well as a ready-to-use checklist for the informed consent process for LST was established. An acceptable Kendall's W coefficient was achieved. CONCLUSION A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions, research studies, medical education, and policy initiatives.
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Affiliation(s)
- Shu Li
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Jing Xie
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ziyi Chen
- Department of Neurology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Yuliang Zhao
- Department of Nephrology, West China Hospital, West China School of Medicine, Chengdu 610041, China
| | - Yali Cong
- Institute of Medical Humanities, School of Foundational Education, Peking University Health Science Center, Beijing 100191, China
| | - Bin Zhao
- Department of Emergency Medicine, Beijing Jishuitan Hospital, Fourth Medical College of Peking University, Beijing 100035, China
| | - Hua Zhang
- Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, China
| | - Hongxia Ge
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Qingbian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Ning Shen
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
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21
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Chen W, Chung JOK, Lam KKW, Molassiotis A. End-of-life communication strategies for healthcare professionals: A scoping review. Palliat Med 2023; 37:61-74. [PMID: 36349371 DOI: 10.1177/02692163221133670] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Timely and effective communication about end-of-life issues, including conversations about prognosis and goals of care, are extremely beneficial to terminally ill patients and their families. However, given the context, healthcare professionals may find it challenging to initiate and facilitate such conversations. Hence, it is critical to improving the available communication strategies to enhance end-of-life communication practices. AIM To summarise the end-of-life communication strategies recommended for healthcare professionals, identify research gaps and inform future research. DESIGN A scoping review performed in accordance with the Arksey and O'Malley framework. DATA SOURCES A literature search was conducted between January 1990 and January 2022 using PubMed, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library and China National Knowledge Infrastructure databases and Google, Google Scholar and ProQuest Dissertations & Theses Global. Studies that described recommended end-of-life communication strategies for healthcare professionals were included. RESULTS Fifty-nine documents were included. Seven themes of communication strategies were found: (a) preparation; (b) exploration and assessment; (c) family involvement; (d) provision and tailoring of information; (e) empathic emotional responses; (f) reframing and revisiting the goals of care; and (g) conversation closure. CONCLUSIONS The themes of communication strategies found in this review provide a framework to integrally promote end-of-life communication. Our results will help inform healthcare professionals, thereby promoting the development of specialised training and education on end-of-life communication.
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Affiliation(s)
- Weilin Chen
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Joyce Oi Kwan Chung
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Katherine Ka Wai Lam
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Alex Molassiotis
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China.,Health and Social Care Research Centre, University of Derby, Derby, UK
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22
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Triggering goals of care conversations in heart failure patients. J Am Assoc Nurse Pract 2022; 34:1174-1180. [DOI: 10.1097/jxx.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/29/2022] [Indexed: 11/06/2022]
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Bechthold AC, Montgomery AP, Fazeli PL, Dionne-Odom JN. Values elicitation among adults making health-related decisions: A concept analysis. Nurs Forum 2022; 57:885-892. [PMID: 35430733 DOI: 10.1111/nuf.12730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/21/2022] [Accepted: 04/03/2022] [Indexed: 06/14/2023]
Abstract
AIM To conduct a concept analysis of values elicitation in the context of health care and treatment decision-making and formulate a conceptual definition. BACKGROUND Values elicitation is a commonly cited term for an activity to help patients identify values and evaluate their application in health care decision-making, yet it remains ambiguous and difficult to differentiate from similar concepts. DESIGN Concept analysis. DATA SOURCE Three databases, including PubMed, CINAHL Plus, and Scopus, were searched from inception to February 2021. REVIEW METHODS Walker and Avant's eight-stage method was used to identify attributes, cases, antecedents, consequences, and empirical referents and formulate a conceptual definition. RESULTS The concept analysis identified 3 attributes, 10 consequences, 7 antecedents, and 3 empirical referents. Our analysis defines values elicitation as an intentional process whereby individuals explore their core beliefs, alone or with others, to (1) determine their preference, or a lack thereof, between health or treatment options, and (2) frame decisions. CONCLUSIONS The findings have the potential to influence the identification, discussion, and measurement of values elicitation by nurses and researchers across disciplines. Further exploration of this concept is warranted as the literature continues to emerge.
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Affiliation(s)
- Avery C Bechthold
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aoyjai P Montgomery
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pariya L Fazeli
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Bartholomew MB. "What are my options?": How to have a goals-of-care conversation. Nurse Pract 2022; 47:15-21. [PMID: 35758914 DOI: 10.1097/01.npr.0000832500.60846.8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients may choose to have a conversation with their providers about their care options. This article presents a guide for NPs for these goals-of-care conversations. NPs having these conversations can follow the strategies presented to plan the discussion, overcome barriers, and offer useful resources and support.
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Affiliation(s)
- Melissa Boettger Bartholomew
- Melissa Boettger Bartholomew is a full-time nursing instructor at DeSales University. She continues to practice as a hospice nurse practitioner. She is also a PhD candidate at Indiana University of Pennsylvania
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Ge C, Goss AL, Crawford S, Goostrey K, Buddadhumaruk P, Shields AM, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor 2022; 4:e0640. [PMID: 35224505 PMCID: PMC8863127 DOI: 10.1097/cce.0000000000000640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.
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Affiliation(s)
- Connie Ge
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adeline L Goss
- Department of Internal Medicine, Division of Neurology, Highland Hospital, Oakland, CA
| | - Sybil Crawford
- Department of Graduate School of Nursing, University of Massachusetts Tan Chingfen Graduate School of Nursing, Worcester, MA
| | - Kelsey Goostrey
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Anne-Marie Shields
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Catherine L Hough
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Oregon Health Sciences University, Portland, OR
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Shannon S Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jay Steingrub
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
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Novaes LMS, Paiva EMDC, O'Mahony A, Garcia ACM. Roleplay as an Educational Strategy in Palliative Care: A Systematic Integrative Review. Am J Hosp Palliat Care 2021; 39:570-580. [PMID: 34350773 DOI: 10.1177/10499091211036703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Simulation activities, such as roleplay, have become established in undergraduate and graduate education in several subjects of healthcare. The objective of this study was to synthesize the evidence available in the literature on the use of roleplay as an educational strategy in palliative care. METHODS Using the method proposed by Whittemore and Knafl, this integrative systematic review was carried out based on the following guiding question: "What is the available evidence in the literature on the use of roleplay as an educational strategy in the teaching of palliative care?" The databases used for the selection of articles were the following: Web of Science, Scopus, Cochrane Library, PubMed, CINAHL, EMBASE, and LILACS. There were no limitations regarding the year of publication or language. RESULTS The articles (n = 34) were grouped into 3 categories, according to the purpose of roleplay use: 1) Use of roleplay as an educational strategy to teach communication in palliative care; 2) Use of roleplay as an educational strategy to teach the communication of bad news, and 3) Use of roleplay as an educational strategy to teach end-of-life care. CONCLUSION Roleplay has been employed in the teaching of palliative care in order to develop skills related to communication and to the provision of end-of-life care. These educational activities have mainly been directed to healthcare students and professionals. Future investigations should further evaluate the efficacy of this teaching strategy, based on studies with more robust designs that allow the establishment of cause-and-effect relationships.
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Affiliation(s)
| | | | - Aoife O'Mahony
- School of Psychology, 2112Cardiff University, Cardiff, Wales, United Kingdom
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Lowe S, Pereira SM, Yardley S. Communication in palliative care during the COVID-19 pandemic: Lessons from rapidly changing, uncertain, complex, and high-stake interventions. Palliat Med 2021; 35:1222-1224. [PMID: 34098795 DOI: 10.1177/02692163211023208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bambach K, Southerland LT. Applying Geriatric Principles to Transitions of Care in the Emergency Department. Emerg Med Clin North Am 2021; 39:429-442. [PMID: 33863470 DOI: 10.1016/j.emc.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model-what matters (patient goals of care), medication, mentation, and mobility-along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.
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Affiliation(s)
- Kimberly Bambach
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Columbus, OH 43210, USA. https://twitter.com/kimbambach
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Columbus, OH 43210, USA.
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Bielinska AM, Archer S, Obanobi A, Soosipillai G, Darzi LA, Riley J, Urch C. Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study. PLoS One 2021; 16:e0247874. [PMID: 33667272 PMCID: PMC7935239 DOI: 10.1371/journal.pone.0247874] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. METHOD This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. RESULTS There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, "Planning for health and wellbeing in the spectrum of illness". Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. CONCLUSION Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.
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Affiliation(s)
- Anna-Maria Bielinska
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
| | - Stephanie Archer
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The University of Cambridge, Cambridge, United Kingdom
| | | | - Gehan Soosipillai
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lord Ara Darzi
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julia Riley
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Catherine Urch
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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30
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Villalobos M, Kreuter M. Inadequate Palliative Care in Lung Disease. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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