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Lim S, Megaris A, Miyakawa L, Filopei J, Dharapak P. Increasing healthcare proxy documentation in an intensive care unit: a quality improvement initiative. BMJ Open Qual 2024; 13:e002854. [PMID: 39084697 PMCID: PMC11293383 DOI: 10.1136/bmjoq-2024-002854] [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: 03/29/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024] Open
Abstract
In New York State, the Health Care Proxy Law allows patients to designate a person they trust to make medical decisions on their behalf should they lose the capacity to do so. In an Intensive Care Unit (ICU) setting, identification of a health care proxy (HCP) is especially important as patients are at heightened risk of losing decision-making capacity during their clinical course. While our hospital has guidelines to solicit and correctly document the patient's HCP information, it is not routinely done. Missing or incomplete HCP documentation is a prevalent issue, with lack of patient education, physical document issues, and time and workflow constraints commonly cited as barriers. We describe the implementation of a small-scale quality improvement project to increase the percentage of completed HCP documentation in our ICU through multi-faceted interventions targeting education, workflow, access, and technology.
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Affiliation(s)
- Steven Lim
- Pulmonary and Critical Care Medicine, Mount Sinai West and Morningside, New York, NY, USA
| | | | - Lina Miyakawa
- Pulmonary and Critical Care Medidine, Mount Sinai Beth Israel, New York, NY, USA
| | - Jason Filopei
- Pulmonary and Critical Care Medidine, Mount Sinai Beth Israel, New York, NY, USA
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Silva CMD, Germano JN, Costa AKDA, Gennari GA, Caruso P, Nassar AP. Association of appropriateness for ICU admission with resource use, organ support and long-term survival in critically ill cancer patients. Intern Emerg Med 2023; 18:1191-1201. [PMID: 36800071 DOI: 10.1007/s11739-023-03216-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023]
Abstract
We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49-0.61 and sHR 0.65, 95% CI 0.53-0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60-7.29 and OR 11.12, 95% CI 8.33-14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors.
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Affiliation(s)
- Carla Marchini Dias Silva
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil.
- Intensive Care Unit, Hospital Vila Nova Star, São Paulo, Brazil.
| | | | | | - Giovanna Alves Gennari
- A.C.Camargo Cancer Center, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A.C.Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Badrinathan A, Ho VP, Tinkoff G, Houck O, Vazquez D, Gerrek M, Kessler A, Rushing A. Are we waiting for the sky to fall? Predictors of withdrawal of life-sustaining support in older trauma patients: A retrospective analysis. J Trauma Acute Care Surg 2023; 94:385-391. [PMID: 36449699 PMCID: PMC9974547 DOI: 10.1097/ta.0000000000003844] [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: 12/05/2022]
Abstract
BACKGROUND Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared with those without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS). METHODS This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program patients 65 years or older who presented between 2017 and 2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS. Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit admissions, and in-hospital cardiac arrests. Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC. RESULTS There were 597,840 patients included: 44,001 patients with an ADLC (7.36%) compared with 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs. 2.48%, p < 0.001). In a 1:1 propensity-matched analysis, patients with ADLC were more likely to undergo WLSS (odds ratio [OR], 2.38' 95% confidence interval [CI], 2.22-2.55), although stronger predictors of WLSS included severity of injury (Injury Severity Score, 25+; OR, 23.84; 95% CI, 21.55-26.36), unplanned intensive care unit admissions (OR, 3.30; 95% CI, 2.89-3.75), and in-hospital cardiac arrests (OR, 4.97; 95% CI, 4.02-6.15). CONCLUSION A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Glen Tinkoff
- Department of Surgery, University Hospitals Cleveland Medical Center
- Northern Ohio Trauma System, Brooklyn Heights, Ohio
| | - Olivia Houck
- Northern Ohio Trauma System, Brooklyn Heights, Ohio
| | - Daniel Vazquez
- Division of Trauma, Cleveland Clinic Foundation, Akron General Hospital, Akron, Ohio
| | - Monica Gerrek
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Center for Biomedical Ethics, The MetroHealth System, Cleveland, OH
| | - Ann Kessler
- Rainbow Babies and Children’s Center for Bioethics, University Hospitals, Cleveland, Ohio
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center
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Arnfeldt CM, Groenvold M, Johnsen AT, Červ B, Deliens L, Dunleavy L, van der Heide A, Kars MC, Lunder U, Miccinesi G, Pollock K, Rietjens JAC, Seymour J. Development of an advance directive ’communication tool’ relevant for patients with advanced cancer in six European countries: Experiences from the ACTION trial. PLoS One 2022; 17:e0271919. [PMID: 35901043 PMCID: PMC9333298 DOI: 10.1371/journal.pone.0271919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 07/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background The ACTION trial evaluated the effect of a modified version of the Respecting Choices´ advance care planning programme in patients with advanced cancer in six European countries. For this purpose, an advance directive acceptable for all six ACTION countries to be used for documenting the wishes and preferences of patients and as a communication tool between patients, their caregivers and healthcare staff, was needed. Aim To describe the development of a multinational cancer specific advance directive, the ´My Preferences form´, which was first based on the 2005 Wisconsin ‘Physician Orders of Life Sustaining Treatment´ Form, to be used within the ACTION trial. Methods Framework analysis of all textual data produced by members of the international project team during the development of the ACTION advance directives (e.g. drafts, emails, meeting minutes…). Setting/participants ACTION consortium members (N = 28) with input from clinicians from participating hospitals (N = 13) and ´facilitators´ (N = 8) who were going to deliver the intervention. Results Ten versions of the ACTION advance directive, the ´My Preferences form´, were developed and circulated within the ACTION consortium. Extensive modifications took place; removal, addition, modification of themes and modification of clinical to lay terminology. The result was a thematically comprehensive advance directive to be used as a communication tool across the six European countries within the ACTION trial. Conclusion This article shows the complex task of developing an advance directive suitable for cancer patients from six European countries; a process which required the resolution of several cross cultural differences in law, ethics, philosophy and practice. Our hope is that this paper can contribute to a deeper conceptual understanding of advance directives, their role in supporting decision making among patients approaching the end of life and be an inspiration to others wishing to develop a disease-specific advance directive or a standardised multinational advance directive.
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Affiliation(s)
- Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine (GP), Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Department of Geriatrics and Palliative Medicine (GP), Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna Thit Johnsen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Branka Červ
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Ixelles, Belgium
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | | | - Marijke C. Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Urška Lunder
- University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Guido Miccinesi
- Center for Oncological Network, Study and Prevention of Cancer (ISPRO), Florence, Italy
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | | | - Jane Seymour
- Division of Nursing and Midwifery, Health Sciences School, University of Sheffield, Sheffield, United Kingdom
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Yamamoto K, Yonekura Y, Nakayama K. Healthcare providers' perception of advance care planning for patients with critical illnesses in acute-care hospitals: a cross-sectional study. BMC Palliat Care 2022; 21:7. [PMID: 34996428 PMCID: PMC8742355 DOI: 10.1186/s12904-021-00900-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background In acute-care hospitals, patients treated in an ICU for surgical reasons or sudden deterioration are treated in an outpatient ward, ICU, and other multiple departments. It is unclear how healthcare providers are initiating advance care planning (ACP) for such patients and assisting them with it. The purpose of this study is to clarify healthcare providers’ perceptions of the ACP support provided to patients receiving critical care in acute-care hospitals. Methods A cross-sectional study was conducted using questionnaires. In this study, 400 acute-care hospitals with ICUs in Japan were randomly selected, and 1490 subjects, including intensivists, surgeons, ICU nurses, surgical floor nurses, and surgical outpatient nurses, participated. Survey items examined whether ICU patients received ACP support, the participants’ degree of confidence in providing ACP support, the patients’ treatment preferences, and the decision-making process, and whether any discussion was conducted on change of values. Results Responses were obtained from 598 participants from 157 hospitals, 41.4% of which reportedly supported ACP provision to ICU patients. The subjects with the highest level of ACP understanding were surgeons (45.8%), and differences in understanding were observed across specialties (P < 0.001). Among the respondents, physicians and nurses expressed high levels of confidence in providing ACP support to patients requiring critical care. However, 15.2% of all the subjects mentioned that they would not attempt to resuscitate the patients. In addition, 25.7% of the participants handed over patients’ values to other departments or hospitals, whereas 25.3% handed over the decision-making process. Conclusions Among the participating hospitals, 40% provided ACP support to patients receiving critical care. The low number is possibly because support providers lack understanding of the content of patients’ ACP or about how to support and use ACP. Second, it is sometimes too late to start providing ACP support after ICU admission. Third, healthcare providers differ in their perception of ACP, widely considered an ambiguous concept. Finally, in acute-care hospitals with different healthcare settings, it is necessary to confirm and integrate the changes in feelings and thoughts of patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00900-5.
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Affiliation(s)
- Kanako Yamamoto
- Department of Critical Care Nursing, Graduate School of Nursing Science, St. Luke's International University, 10-1, Akashi-cho, Tokyo, Japan. .,Department of Nursing Informatics, Graduate School of Nursing Science, St. Luke's International University, 10-1, Akashi-cho, Tokyo, Japan.
| | - Yuki Yonekura
- Department of Critical Care Nursing, Graduate School of Nursing Science, St. Luke's International University, 10-1, Akashi-cho, Tokyo, Japan.,Department of Nursing Informatics, Graduate School of Nursing Science, St. Luke's International University, 10-1, Akashi-cho, Tokyo, Japan
| | - Kazuhiro Nakayama
- Department of Nursing Informatics, Graduate School of Nursing Science, St. Luke's International University, 10-1, Akashi-cho, Tokyo, Japan
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Huemer M, Jahn-Kuch D, Hofmann G, Andritsch E, Farkas C, Schaupp W, Masel EK, Jost PJ, Pichler M. Trends and Patterns in the Public Awareness of Palliative Care, Euthanasia, and End-of-Life Decisions in 3 Central European Countries Using Big Data Analysis From Google: Retrospective Analysis. J Med Internet Res 2021; 23:e28635. [PMID: 34542419 PMCID: PMC8491122 DOI: 10.2196/28635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited. Objective The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions. Methods We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program. Results Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: −24.48%, P=.02; Germany: −14.95%, P<.001; Switzerland: −11.75%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66% (P<.001) in Switzerland and decreased by 2.85% (P<.001) in Germany. Conclusions Our results demonstrate that legal measures securing patients’ autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same.
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Affiliation(s)
- Matthias Huemer
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Jahn-Kuch
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Guenter Hofmann
- Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Andritsch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Clemens Farkas
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Walter Schaupp
- Institute of Moral Theology, University of Graz, Graz, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department of Medicine I and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Department of Internal Medicine III - Hematooncology, Technical University of Munich School of Medicine, Technical University of Munich, Munich, Germany
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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