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Underwood M, Noufaily A, Bain C, Harlock J, Griffiths F, Huxley C, Perkins G, Rees S, Slowther AM. Public attitudes to emergency care treatment plans: a population survey of Great Britain. BMJ Open 2024; 14:e080162. [PMID: 39313284 PMCID: PMC11429361 DOI: 10.1136/bmjopen-2023-080162] [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] [Indexed: 09/25/2024] Open
Abstract
OBJECTIVES To measure community attitudes to emergency care and treatment plans (ECTPs). DESIGN Population survey. SETTING Great Britain. PARTICIPANTS As part of the British Social Attitudes Survey, sent to randomly selected addresses in Great Britain, 1135 adults completed a module on ECTPs. The sample was nationally representative in terms of age and location, 619 (55%) were female and 1005 (89%) were of white origin. OUTCOME MEASURES People's attitudes having an ECTP for themselves now, and in the future; how comfortable they might be having a discussion about an ECTP and how they thought such a plan might impact on their future care. RESULTS Predominantly, respondents were in favour of people being able to have an ECTP, with 908/1135 (80%) being at least somewhat in favour. People in good health were less likely than those with activity-limiting chronic disease to want a plan at present (52% vs 64%, OR 1.78 (95% CI 1.30 to 2.45) p<0.001). Developing a long-term condition or becoming disabled would lead 42% (467/1112) and 43% (481/1112) of individuals, respectively, to want an ECTP. More, 634/1112 (57%) would want an ECTP if they developed a life-threatening condition. Predominantly, 938/1135 (83%) respondents agreed that an ECTP would help avoid their family needing to make difficult decisions on their behalf, and 939/1135 (83%) that it would ensure doctors and nurses knew their wishes. Nevertheless, a small majority-628/1135 (55%)-agreed that there was a serious risk of the plan being out of date when needed. A substantial minority-330/1135 (29%)-agreed that an ECTP might result in them not receiving life-saving treatment. CONCLUSIONS There is general support for the use of ECTPs by people of all ages. Nevertheless, many respondents felt these might be out of date when needed and prevent people receiving life-saving treatment.
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Affiliation(s)
- Martin Underwood
- Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | | | | | | | - Sophie Rees
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Gane K, Sparks T, Thomas E. Perceptions, practices and preferences of veterinarians and veterinary nurses in the UK on consent for cardiopulmonary resuscitation in pets. J Small Anim Pract 2024. [PMID: 39243164 DOI: 10.1111/jsap.13778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 07/04/2024] [Accepted: 08/07/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVES Cardiopulmonary resuscitation can be a difficult topic to discuss. The barriers surrounding its discussion are well documented in human medicine but have not previously been examined in veterinary medicine. The objectives of this study is to describe the perceptions, practices and preferences of veterinarians and registered veterinary nurses towards discussing cardiopulmonary resuscitation with pet owners. MATERIALS AND METHODS An online survey was circulated to veterinarians and registered veterinary nurses in the UK. Open and closed questions were used, with multiple choice and free text answer formats, all of which related to the timing and content, participants' preferences and perceived barriers to cardiopulmonary resuscitation discussions. RESULTS In total, 290 responses met the inclusion criteria. Almost half of participants [140/290 (48%)] worked in first opinion practice. In total, 100 of 290 (34%) participants were "very likely" to discuss cardiopulmonary resuscitation preferences on admission. However, 244 of 272 (90%) said they would rather discuss cardiopulmonary resuscitation prospectively than at the time of a critical event. Most respondents [174/290 (60%)] stated that their practice does not include resuscitation preferences on admission consent forms despite 163 of 290 (56%) "strongly agreeing" that cardiopulmonary resuscitation preferences should be routinely discussed on admission. Over half [168/290 (58%)] never discussed costs associated with cardiopulmonary resuscitation and 67 of 290 (23%) never discussed likelihood of survival to discharge with the most common reason being "unaware of survival statistics." Barriers to discussion included fear of causing upset, concerns for owner reactions and unrealistic owner expectations. CLINICAL SIGNIFICANCE Veterinary professionals in the UK face multiple challenges when discussing cardiopulmonary resuscitation with pet owners. Whilst communication skills are an increasing area of focus in veterinary education, specific teaching on the topic of cardiopulmonary resuscitation discussion may be beneficial. Pet owner education may also mitigate some of the challenges to conversation.
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Affiliation(s)
- K Gane
- Dick White Referrals, London, UK
| | - T Sparks
- Waltham Petcare Science Institute, Leicestershire, UK
| | - E Thomas
- Dick White Referrals, London, UK
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Warner BE, Wells M, Vindrola-Padros C, Brett SJ. Shared decision-making with older people on TReatment Escalation planning for Acute deterioration in the emergency Medical Setting: a qualitative study of Clinicians' perspectives (STREAMS-C). Age Ageing 2024; 53:afae204. [PMID: 39323400 PMCID: PMC11424886 DOI: 10.1093/ageing/afae204] [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: 01/02/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Shared decision-making (SDM) is increasingly expected in healthcare systems prioritising patient autonomy. Treatment escalation plans (TEPs) outline contingency for medical intervention in the event of patient deterioration. This study aimed to understand clinicians' perspectives on SDM in TEP for older patients in the acute medical setting. METHODS This was a qualitative study following a constructivist approach. Semistructured interviews with vignettes were conducted with 26 consultant and registrar doctors working in emergency medicine, general internal medicine, intensive care medicine and palliative care medicine. Reflexive thematic analysis was performed. RESULTS There were three themes: 'An unequal partnership', 'Options without equipoise' and 'Decisions with shared understanding'. Clinicians' expertise in synthesising complex, uncertain clinical information was contrasted with perceived patient unfamiliarity with future health planning and medical intervention. There was a strong sense of morality underpinning decision-making and little equipoise about appropriate TEP decisions. Communication around the TEP was important, and clinicians sought control over the high-stakes decision whilst avoiding conflict and achieving shared understanding. CONCLUSIONS Clinicians take responsibility for securing a 'good' TEP decision for older patients in the acute medical setting. They synthesise clinical data with implicit ethical reasoning according to their professional predictions of qualitative and quantitative success following medical intervention. SDM is seldom considered a priority for this context. Nonetheless, avoidance of conflict, preserving the clinical relationship and shared understanding with the patient and family are important.
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Affiliation(s)
- Bronwen E Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
| | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
- Directorate of Nursing, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | | | - Stephen J Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust, London, W120HS, UK
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Grange R, Carter B, Chamberlain C, Brooks M, Nitharsan R, Twine C, Braude P. Amputation and advance care plans: An observational study exploring decision making and long-term outcomes in a vascular centre. Vascular 2024; 32:824-833. [PMID: 36888982 DOI: 10.1177/17085381231162733] [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: 03/10/2023]
Abstract
BACKGROUND Half of those undergoing major lower limb amputation for peripheral arterial disease die within 1 year. Advance care planning reduces days in hospital and increases the chance of dying in a preferred place. AIM To investigate the prevalence and content of advance care planning for people having a lower limb amputation due to acute or chronic limb-threatening ischaemia or diabetes. Secondary aims were to explore its association with mortality, and length of hospital stay. DESIGN A retrospective observational cohort study. The intervention was advance care planning. SETTING/PARTICIPANTS Patients admitted to the South West England Major Arterial Centre between 1 January 2019 and 1 January 2021 who received unilateral or bilateral below, above, or through knee amputation due to acute or chronic limb-threatening ischaemia or diabetes. RESULTS 116 patients were included in the study. 20.7% (n = 24) died within 1 year. 40.5% (n = 47) had an advance care planning discussion of which all included cardiopulmonary resuscitation decisions with few exploring other options. Patients who were more likely to have advance care planning discussions were ≥75 years (aOR = 5.58, 95%CI 1.56-20.0), female (aOR = 3.24, 95%CI 1.21-8.69), and had multimorbidity (Charlson Comorbidity Index ≥5, aOR = 2.97, 95%CI 1.11-7.92). Discussions occurred more often in the emergency pathway and were predominantly initiated by physicians. Advance care planning was associated with increased mortality (aHR = 2.63, 95%CI 1.01, 5.02) and longer hospital stay (aHR = 0.52, 95%CI 0.32-0.83). CONCLUSIONS Despite a high risk of death for all patients in the months following amputation, advance care planning occurred in fewer than half of people and mostly focused on resuscitation.
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Affiliation(s)
- Robert Grange
- Department of Medicine for Older People, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Charlotte Chamberlain
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Marcus Brooks
- Vascular Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Christopher Twine
- Vascular Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Philip Braude
- Department of Medicine for Older People, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Shepherd V, Hood K, Wood F. 'It's not making a decision, it's prompting the discussions': a qualitative study exploring stakeholders' views on the acceptability and feasibility of advance research planning (CONSULT-ADVANCE). BMC Med Ethics 2024; 25:80. [PMID: 39039465 PMCID: PMC11265470 DOI: 10.1186/s12910-024-01081-5] [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: 04/03/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Health and care research involving people who lack capacity to consent requires an alternative decision maker to decide whether they participate or not based on their 'presumed will'. However, this is often unknown. Advance research planning (ARP) is a process for people who anticipate periods of impaired capacity to prospectively express their preferences about research participation and identify who they wish to be involved in future decisions. This may help to extend individuals' autonomy by ensuring that proxy decisions are based on their actual wishes. This qualitative study aimed to explore stakeholders' views about the acceptability and feasibility of ARP and identify barriers and facilitators to its implementation in the UK. METHODS We conducted semi-structured interviews with 27 researchers, practitioners, and members of the public who had participated in a preceding survey. Interviews were conducted remotely between April and November 2023. Data were analysed thematically. RESULTS Participants were supportive of the concept of ARP, with differing amounts of support for the range of possible ARP activities depending on the context. Six main themes were identified: (1) Planting a seed - creating opportunities to initiate/engage with ARP; (2) A missing part of the puzzle - how preferences expressed through ARP could help inform decisions; (3) Finding the sweet spot - optimising the timing of ARP; (4) More than a piece of paper - finding the best mode for recording preferences; (5) Keeping the door open to future opportunities - minimising the risk of unintended consequences; and (6) Navigating with a compass - principles underpinning ARP to ensure safeguarding and help address inequalities. Participants also identified a number of implementation challenges, and proposed facilitative strategies that might overcome them which included embedding advance research planning in existing future planning processes and research-focused activities. CONCLUSIONS This study provides a routemap to implementing ARP in the UK to enable people anticipating impaired capacity to express their preferences about research, thus ensuring greater opportunities for inclusion of this under-served group, and addressing the decisional burden experienced by some family members acting as proxies. Development of interventions and guidance to support ARP is needed, with a focus on ensuring accessibility.
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Affiliation(s)
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Fiona Wood
- PRIME Centre Wales, Cardiff, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Anik E, Hurlow A, Azizoddin D, West R, Muehlensiepen F, Clarke G, Mitchell S, Allsop M. Characterising trends in the initiation, timing, and completion of recommended summary plan for emergency care and treatment (ReSPECT) plans: Retrospective analysis of routine data from a large UK hospital trust. Resuscitation 2024; 200:110168. [PMID: 38458416 DOI: 10.1016/j.resuscitation.2024.110168] [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: 12/06/2023] [Revised: 01/30/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
AIM To assess patient socio-demographic and disease characteristics associated with the initiation, timing, and completion of emergency care and treatment planning in a large UK-based hospital trust. METHODS Secondary retrospective analysis of data across 32 months extracted from digitally stored Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans within the electronic health record system of an acute hospital trust in England, UK. RESULTS Data analysed from ReSPECT plans (n = 23,729), indicate an increase in the proportion of admissions having a plan created from 4.2% in January 2019 to 6.9% in August 2021 (mean = 8.1%). Forms were completed a median of 41 days before death (a median of 58 days for patients with capacity, and 21 days for patients without capacity). Do not attempt cardiopulmonary resuscitation was more likely to be recorded for patients lacking capacity, with increasing age (notably for patients aged over 74 years), being female and the presence of multiple disease groups. 'Do not attempt cardiopulmonary resuscitation' was less likely to be recorded for patients having ethnicity recorded as Asian or Asian British and Black or Black British compared to White. Having a preferred place of death recorded as 'hospital' led to a five-fold increase in the likelihood of dying in hospital. CONCLUSION Variation in the initiation, timing, and completion of ReSPECT plans was identified by applying an evaluation framework. Digital storage of ReSPECT plan data presents opportunities for assessing trends and completion of the ReSPECT planning process and benchmarking across sites. Further research is required to monitor and understand any inequity in the implementation of the ReSPECT process in routine care.
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Affiliation(s)
- Evrim Anik
- Leeds Institute of Health Sciences, University of Leeds, UK; Leeds Dental Institute, University of Leeds, UK.
| | - Adam Hurlow
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, UK.
| | - Felix Muehlensiepen
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Germany.
| | - Gemma Clarke
- Leeds Institute of Health Sciences, University of Leeds, UK.
| | - Sarah Mitchell
- Leeds Institute of Health Sciences, University of Leeds, UK.
| | - Matthew Allsop
- Leeds Institute of Health Sciences, University of Leeds, UK.
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Fritz Z. ReSPECT the process: The importance of good conversations and documentation in advance care planning. Resuscitation 2024; 200:110249. [PMID: 38788793 DOI: 10.1016/j.resuscitation.2024.110249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Affiliation(s)
- Zoë Fritz
- THIS Institute (The Healthcare Improvement Studies Institute) Strangeways Research Laboratory, 2 Worts' Causeway, Cambridge CB1 8RN, and Department of Acute Medicine Cambridge University Hospitals, United Kingdom.
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Underwood M, Noufaily A, Blanchard H, Dale J, Harlock J, Gill P, Griffiths F, Spencer R, Slowther AM. GPs' views on emergency care treatment plans: an online survey. BJGP Open 2024; 8:BJGPO.2023.0192. [PMID: 38191186 PMCID: PMC11300997 DOI: 10.3399/bjgpo.2023.0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A holistic approach to emergency care treatment planning is needed to ensure that patients' preferences are considered should their clinical condition deteriorate. To address this, emergency care and treatment plans (ECTPs) have been introduced. Little is known about their use in general practice. AIM To find out GPs' experiences of, and views on, using ECTPs. DESIGN & SETTING Online survey of GPs practising in England. METHOD A total of 841 GPs were surveyed using the monthly online survey provided by medeConnect, a market research company. RESULTS Forty-one per cent of responders' practices used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans for ECTP, 8% used other ECTPs, and 51% used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. GPs were the predominant professional group completing ECTPs in the community. There was broad support for a wider range of community-based health and social care professionals being able to complete ECTPs. There was no system for reviewing ECTPs in 20% of responders' practices. When compared with using a DNACPR form, GPs using a ReSPECT form for ECTP were more comfortable having conversations about emergency care treatment with patients (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.1 to 2.69) and family members (OR =1.85, 95% CI = 1.19 to 2.87). CONCLUSION The potential benefits and challenges of widening the pool of health and social care professionals initiating and/or completing the ECTP process needs consideration. ReSPECT plans appear to make GPs more comfortable with ECTP discussions, supporting their implementation. Practice-based systems for reviewing ECTP decisions should be strengthened.
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Affiliation(s)
- Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Spencer
- Warwick Medical School, University of Warwick, Coventry, UK
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Eli K, Harlock J, Huxley CJ, Bernstein C, Mann C, Spencer R, Griffiths F, Slowther AM. Patient and relative experiences of the ReSPECT process in the community: an interview-based study. BMC PRIMARY CARE 2024; 25:115. [PMID: 38632508 PMCID: PMC11022317 DOI: 10.1186/s12875-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/19/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Celia Bernstein
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Claire Mann
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Rachel Spencer
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
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Adenwalla SF, O'Halloran P, Faull C, Murtagh FEM, Graham-Brown MPM. Advance care planning for patients with end-stage kidney disease on dialysis: narrative review of the current evidence, and future considerations. J Nephrol 2024; 37:547-560. [PMID: 38236475 PMCID: PMC11150316 DOI: 10.1007/s40620-023-01841-3] [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: 08/15/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
Patients with end-stage kidney disease (ESKD) have a high symptom-burden and high rates of morbidity and mortality. Despite this, evidence has shown that this patient group does not have timely discussions to plan for deterioration and death, and at the end of life there are unmet palliative care needs. Advance care planning is a process that can help patients share their personal values and preferences for their future care and prepare for declining health. Earlier, more integrated and holistic advance care planning has the potential to improve access to care services, communication, and preparedness for future decision-making and changing circumstances. However, there are many barriers to successful implementation of advance care planning in this population. In this narrative review we discuss the current evidence for advance care planning in patients on dialysis, the data around the barriers to advance care planning implementation, and interventions that have been trialled. The review explores whether the concepts and approaches to advance care planning in this population need to be updated to encompass current and future care. It suggests that a shift from a problem-orientated approach to a goal-orientated approach may lead to better engagement, with more patient-centred and satisfying outcomes.
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Affiliation(s)
- S F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK.
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK.
| | - P O'Halloran
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - C Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - M P M Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 9HN, UK
- NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
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Gross J, Koffman J. Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review. PLoS One 2024; 19:e0299933. [PMID: 38498549 PMCID: PMC10947705 DOI: 10.1371/journal.pone.0299933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/17/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. AIM To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. DESIGN Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. DATA SOURCES Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. RESULTS Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. CONCLUSIONS Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.
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Affiliation(s)
- Jamie Gross
- Northwick Park and Central Middlesex Hospitals, London North West University Healthcare NHS Trust, Harrow, United Kingdom
- King’s College London, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom
| | - Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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Nolan JP, Soar J, Kane AD, Moppett IK, Armstrong RA, Kursumovic E, Cook TM. Peri-operative decisions about cardiopulmonary resuscitation among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024; 79:186-192. [PMID: 37991058 DOI: 10.1111/anae.16179] [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: 10/17/2023] [Indexed: 11/23/2023]
Abstract
Current guidance recommends that, in most circumstances, cardiopulmonary resuscitation should be attempted when cardiac arrest occurs during anaesthesia, and when a patient has a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation, this should be suspended. How this guidance is translated into everyday clinical practice in the UK is currently unknown. Here, as part of the 7th National Audit Project of the Royal College of Anaesthetists, we have: assessed the rates of pre-operative 'do not attempt cardiopulmonary resuscitation' recommendations via an activity survey of all cases undertaken by anaesthetists over four days in each participating site; and analysed our one-year case registry of peri-operative cardiac arrests to understand the rates of cardiac arrest in patients who had 'do not attempt cardiopulmonary resuscitation' decisions pre-operatively. In the activity survey, among 20,717 adults (aged > 18 y) undergoing surgery, 595 (3%) had a 'do not attempt cardiopulmonary resuscitation' recommendation pre-operatively, of which less than a third (175, 29%) were suspended. Of the 881 peri-operative cardiac arrest reports, 54 (6%) patients had a 'do not attempt cardiopulmonary resuscitation' recommendation made pre-operatively and of these 38 (70%) had a clinical frailty scale score ≥ 5. Just under half (25, 46%) of these 'do not attempt cardiopulmonary resuscitation' recommendations were formally suspended at the time of anaesthesia and surgery. One in five of these patients with a 'do not attempt cardiopulmonary resuscitation' recommendation who had a cardiac arrest survived to leave hospital and of the seven patients with documented modified Rankin Scale scores before and after cardiac arrest, four remained the same and three had worse scores. Very few patients who had a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation had a peri-operative cardiac arrest, and when cardiac arrest did occur, return of spontaneous circulation was achieved in 57%, although > 50% of these patients subsequently died before discharge from hospital.
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Affiliation(s)
- J P Nolan
- Warwick Clinical Trials Unit, University of Warwick, UK
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - A D Kane
- Health Services Research Centre, Royal College of Anaesthetists, Red Lion Square, UK
- Department of Anaesthesia, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK
| | - I K Moppett
- Health Services Research Centre, Royal College of Anaesthetists, Red Lion Square, UK
- University of Nottingham, Nottingham, UK
| | - R A Armstrong
- Health Services Research Centre, Royal College of Anaesthetists, Red Lion Square, UK
- Severn Deanery, Bristol, UK
| | - E Kursumovic
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Health Services Research Centre, Royal College of Anaesthetists, Red Lion Square, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- University of Bristol, Bristol, UK
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13
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Smith MA, Brøchner AC, Nedergaard HK, Jensen HI. "Gives peace of mind" - Relatives' perspectives of end-of-life conversations. Palliat Support Care 2023:1-8. [PMID: 37982296 DOI: 10.1017/s1478951523001633] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Planning for end-of-life (EOL) and future treatment and care through advance care planning (ACP) is being increasingly implemented in different healthcare settings, and interest in ACP is growing. Several studies have emphasized the importance of relatives participating in conversations about wishes for EOL and being included in the process. Likewise, research has highlighted how relatives can be a valuable resource in an emergency setting. Although relatives have a significant role, few studies have investigated their perspectives of ACP and EOL conversations. This study explores relatives' experiences of the benefits and disadvantages of having conversations about wishes for EOL treatment. METHODS Semi-structured telephone interviews were held with 29 relatives who had participated in a conversation about EOL wishes with a patient and physician 2 years prior in a variety of Danish healthcare settings. The relatives were interviewed between September 2020 and June 2022. Content analysis was performed on the qualitative data. RESULTS The interviews revealed two themes: "gives peace of mind" and "enables more openness and common understanding of EOL." Relatives found that conversations about EOL could help assure that patients were heard and enhance their autonomy. These conversations relieved the relatives of responsibility by clarifying or confirming the patients' wishes, and they also made the relatives reflect on their own wishes for EOL. Moreover, they helped patients and relatives address other issues regarding EOL and made wishes more visible across settings. SIGNIFICANCE OF RESULTS The results indicate that conducting conversations about wishes for EOL treatment and having relatives participate in those conversations were perceived as beneficial for both relatives and patients. Involving relatives in ACP should be prioritized by physicians and healthcare personnel when holding conversations about EOL.
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Affiliation(s)
- Mette A Smith
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Anne C Brøchner
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Helene K Nedergaard
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Hanne I Jensen
- Department of Anesthesiology and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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14
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Muir R, Carlini J, Crilly J, Ranse J. Patient and public involvement in emergency care research: a scoping review of the literature. Emerg Med J 2023; 40:596-605. [PMID: 37280045 DOI: 10.1136/emermed-2022-212514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/13/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Establishing the benefits of patient and public involvement (PPI) in emergency care research is important to improve the quality and relevance of research. Little is known about the extent of PPI in emergency care research, its methodological and reporting quality. This scoping review aimed to establish the extent of PPI in emergency care research, identify PPI strategies and processes and assess the quality of reporting on PPI in emergency care research. METHODS Keyword searches of five databases (OVID MEDLINE, Elsevier EMBASE, EBSCO CINAHL, PsychInfo, Cochrane Central Register of Controlled trials); hand searches of 12 specialist journals and citation searches of the included journal articles were performed. A patient representative contributed to research design and co-authored this review. RESULTS A total of 28 studies reporting PPI from the USA, Canada, UK, Australia and Ghana were included. The quality of reporting was variable, with only seven studies satisfying all Guidance for Reporting Involvement of Patients and the Public short form reporting criteria. None of the included studies adequately described all the key aspects of reporting the impact of PPI. CONCLUSION Relatively few emergency care studies comprehensively describe PPI. Opportunity exists to improve the consistency and quality of reporting of PPI in emergency care research. Further research is required to better understand the specific challenges for implementing PPI in emergency care research, and to determine whether emergency care researchers have adequate resources, education and funding to undertake and report involvement.
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Affiliation(s)
- Rachel Muir
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Joan Carlini
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Consumer Advisory Group, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Department of Marketing, Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
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15
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Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
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Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
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16
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Moorlock G, Draper H. Proposal to support making decisions about the organ donation process. JOURNAL OF MEDICAL ETHICS 2023; 49:434-438. [PMID: 35953297 DOI: 10.1136/jme-2022-108323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/07/2022] [Indexed: 05/24/2023]
Abstract
In this paper, we propose a novel approach to permit members of the public opportunity to record more nuanced wishes in relation to organ donation. Recent developments in organ donation and procurement have made the associated processes potentially more multistaged and complex than ever. At the same time, opt-out legislation has led to a more simplistic recording of wishes than ever. We argue that in order to be confident that a patient would really wish to go ahead with the various interventions and procedures that now accompany organ donation, more nuanced information than a simple 'yes' or 'no' may be required. This is of particular importance for donation after circulatory death, where some interventions to facilitate donation occur when the patient is still alive. We propose the implementation of an online form to allow people to record more nuanced wishes in relation to donation, including an indication of competing wishes and how these should be weighed into decision-making. We argue that this approach will promote autonomous decision-making for the public, potentially reduce difficulties that family members encounter at the time of organ donation, and should make medical staff more confident that they are truly acting according to the wishes and best interests of their patients.
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Affiliation(s)
- Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Heather Draper
- Warwick Medical School, University of Warwick, Coventry, UK
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17
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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Tomkow L, Dewhurst F, Hubmann M, Straub C, Damisa E, Hanratty B, Todd C. 'That's as hard a decision as you will ever have to make': the experiences of people who discussed Do Not Attempt Cardiopulmonary Resuscitation on behalf of a relative during the COVID-19 pandemic. Age Ageing 2023; 52:afad087. [PMID: 37382203 PMCID: PMC10308352 DOI: 10.1093/ageing/afad087] [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: 10/05/2022] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND COVID-19 brought additional challenges to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making, which was already a contentious issue. In the UK, reports of poor DNACPR decision-making and communication emerged in 2020, including from the regulator, the Care Quality Commission. This paper explores the experiences of people who discussed DNACPR with a healthcare professional on behalf of a relative during the coronavirus pandemic, with the aim of identifying areas of good practice and what needs to be improved. METHODS a total of 39 people participated in semi-structured interviews via video conferencing software or telephone. Data were evaluated using Framework Analysis. FINDINGS results are presented around three main themes: understanding, communication and impact. Participants' understanding about DNACPR was important, as those with better understanding tended to reflect more positively on their discussions with clinicians. The role of relatives in the decision-making process was a frequent source of misunderstanding. Healthcare professionals' communication skills were important. Where discussions went well, relatives were given clear explanations and the opportunity to ask questions. However many relatives felt that conversations were rushed. DNACPR discussions can have a lasting impact-relatives reported them to be significant moments in care journeys. Many relatives perceived that they were asked to decide whether their relative should receive CPR and described enduring emotional consequences, including guilt. CONCLUSION the pandemic has illuminated deficiencies in current practice around DNACPR discussion, which can have difficult to anticipate and lasting negative consequences for relatives. This research raises questions about the current approach to DNACPR decision-making.
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Affiliation(s)
| | | | | | | | | | - Barbara Hanratty
- National Institute for Health and Care Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne NE4 5PL, UK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, National Institute for Health and Care Research, Older People and Frailty Policy Research Unit, The University of Manchester, Manchester M13 9PL, UK
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19
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Warner BE, Harry A, Wells M, Brett SJ, Antcliffe DB. Escalation to intensive care for the older patient. An exploratory qualitative study of patients aged 65 years and older and their next of kin during the COVID-19 pandemic: the ESCALATE study. Age Ageing 2023; 52:7127657. [PMID: 37083851 PMCID: PMC10120351 DOI: 10.1093/ageing/afad035] [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: 06/20/2022] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND older people comprise the majority of hospital medical inpatients so decision-making regarding admission of this cohort to the intensive care unit (ICU) is important. ICU can be perceived by clinicians as overly burdensome for patients and loved ones, and long-term impact on quality of life considered unacceptable, effecting potential bias against admitting older people to ICU. The COVID-19 pandemic highlighted the challenge of selecting those who could most benefit from ICU. OBJECTIVE this qualitative study aimed to explore the views and recollections of escalation to ICU from older patients (aged ≥ 65 years) and next of kin (NoK) who experienced a COVID-19 ICU admission. SETTING the main site was a large NHS Trust in London, which experienced a high burden of COVID-19 cases. SUBJECTS 30 participants, comprising 12 patients, 7 NoK of survivor and 11 NoK of deceased. METHODS semi-structured interviews with thematic analysis using a framework approach. RESULTS there were five major themes: inevitability, disconnect, acceptance, implications for future decision-making and unique impact of the COVID-19 pandemic. Life was highly valued and ICU perceived to be the only option. Prior understanding of ICU and admission decision-making explanations were limited. Despite benefit of hindsight, having experienced an ICU admission and its consequences, most could not conceptualise thresholds for future acceptable treatment outcomes. CONCLUSIONS in this study of patients ≥65 years and their NoK experiencing an acute ICU admission, survival was prioritised. Despite the ordeal of an ICU stay and its aftermath, the decision to admit and sequelae were considered acceptable.
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Affiliation(s)
- Bronwen E Warner
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Critical Care Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Alice Harry
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthetics, Royal Free London NHS Foundation Trust, London, UK
| | - Mary Wells
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen J Brett
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Critical Care Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - David B Antcliffe
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Critical Care Medicine, Imperial College Healthcare NHS Trust, London, UK
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20
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Kesten JM, Redwood S, Pullyblank A, Tavare A, Pocock L, Brant H, Hill EM, Tutaev M, Shum RZ, Banks J. Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study. Age Ageing 2022; 51:6770071. [PMID: 36273344 PMCID: PMC9588387 DOI: 10.1093/ageing/afac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS A qualitative research design using semi-structured interviews. RESULTS Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.
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Affiliation(s)
- Joanna May Kesten
- Address correspondence to: Joanna May Kesten, NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
| | - Sabi Redwood
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Anne Pullyblank
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK,North Bristol NHS Trust, Bristol, UK
| | - Alison Tavare
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK
| | - Lucy Pocock
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Heather Brant
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Elizabeth M Hill
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | | | - Rui Zhi Shum
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jon Banks
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
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21
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Qureshi SP, Jones D, Dewar A. Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature. QUALITATIVE HEALTH RESEARCH 2022; 32:1881-1896. [PMID: 35981561 PMCID: PMC9511242 DOI: 10.1177/10497323221119939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.
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Affiliation(s)
- Shaun Peter Qureshi
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Derek Jones
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Avril Dewar
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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22
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McDermott A, Woodall CA, Chamberlain C, Selman L, Pocock LV. Which patients received a ReSPECT form, what was documented and what were the patient outcomes? A protocol for a retrospective observational study investigating the impact of the COVID-19 pandemic on the implementation of the ReSPECT process. BMJ Open 2022; 12:e060253. [PMID: 35820746 PMCID: PMC9277023 DOI: 10.1136/bmjopen-2021-060253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/16/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a UK advance care planning (ACP) initiative aiming to standardise the process of creating personalised recommendations for a person's clinical care in a future emergency and therefore improve person-focused care. Implementation of the ReSPECT process across a large geographical area, involving both community and secondary care, has not previously been studied. In particular, it not known whether such implementation is associated with any change in outcomes for those patients with a ReSPECT form.Implementation of ReSPECT in the Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) area overlapped with the first UK COVID-19 wave. It is unclear what impact the pandemic had on the implementation of ReSPECT and if this affected the type of patients who underwent the ReSPECT process, such as those with specific diagnoses or living in care homes. Patterns of clinical recommendations documented on ReSPECT forms during the first year of its implementation may also have changed, particularly with reference to the pandemic.To determine the equity and potential benefits of implementation of the ReSPECT form process in BNSSG and contribute to the ACP evidence base, this study will describe the characteristics of patients in the BNSSG area who had a completed ReSPECT form recorded in their primary care medical records before, during and after the first wave of the COVID-19 pandemic; describe the content of ReSPECT forms; and analyse outcomes for those patients who died with a ReSPECT form. METHODS AND ANALYSIS We will perform an observational retrospective study on data, collected from October 2019 for 12 months. Data will be exported from the CCG Public Health Management data resource, a pseudonymised database linking data from organisations providing health and social care to people across BNSSG. Descriptive statistics of sociodemographic and health-related variables for those who completed the ReSPECT process with a clinician and had a documented ReSPECT form in their notes, in addition to their ReSPECT form responses, will be compared between before, during and after first COVID-19 wave groups. Additionally, routinely collected outcomes for patients who died in our study period will be compared between those who completed the ReSPECT process with a community clinician, hospital clinician or not at all. These include emergency department attendances, emergency hospital admissions, community nurse home visits, hospice referrals, anticipatory medication prescribing, place of death and if the patient died in preferred place of death. ETHICS AND DISSEMINATION Approval has been obtained from a National Health Service Research Ethics Committee (20/YH/0185). Findings will be disseminated to policy decision-makers, care providers and the public through scientific meetings and peer-reviewed publication.
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Affiliation(s)
- Adam McDermott
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Claire A Woodall
- Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Charlotte Chamberlain
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Victoria Pocock
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
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Mentzelopoulos SD, Couper K, Raffay V, Djakow J, Bossaert L. Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation. J Clin Med 2022; 11:4005. [PMID: 35887769 PMCID: PMC9316602 DOI: 10.3390/jcm11144005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores. METHODS The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades. RESULTS Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047). CONCLUSIONS In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675 Athens, Greece
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham, NHS Foundation Trust, Birmingham B15 2TH, UK;
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus;
- Serbian Resuscitation Council, 21102 Novi Sad, Serbia
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, 26801 Hořovice, Czech Republic;
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
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Implementation of ReSPECT in acute hospitals: A retrospective observational study. Resuscitation 2022; 178:26-35. [PMID: 35779800 DOI: 10.1016/j.resuscitation.2022.06.020] [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: 04/26/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
AIMS To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion. METHODS A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. RESULTS The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. CONCLUSIONS ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. STUDY REGISTRATION https://www.isrctn.com/ISRCTN11112933.
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Eli K, Huxley CJ, Hawkes CA, Perkins GD, Slowther AM, Griffiths F. Why are some ReSPECT conversations left incomplete? A qualitative case study analysis. Resusc Plus 2022; 10:100255. [PMID: 35734306 PMCID: PMC9207560 DOI: 10.1016/j.resplu.2022.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results We identified two themes, both focused on 'mismatch': (1) Mismatch between the doctor's clinical priorities and the patient's/family's immediate needs; and (2) mismatch between the doctor's conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient's life, and the patient's/family's understandings of these concepts. Conclusions This case study analysis of six ReSPECT conversations found that mismatch between doctors' priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, UK
| | | | | | - Gavin D. Perkins
- Warwick Medical School, University of Warwick, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
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Kotha S, Berry P. The writing was on the wall: Decision making near the end of life in advanced liver disease. PROGRESS IN PALLIATIVE CARE 2022. [DOI: 10.1080/09699260.2022.2067702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy’s and St Thomas’ Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy’s and St Thomas’ Foundation Trust, London, UK
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Bird J, Wilson F. Do not resuscitate orders in the time of COVID-19: Exploring media representations and implications for public and professional understandings. PROGRESS IN PALLIATIVE CARE 2022. [DOI: 10.1080/09699260.2022.2052505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joanne Bird
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Fiona Wilson
- Health Sciences School, University of Sheffield, Sheffield, UK
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Eli K, Hawkes C, Perkins GD, Slowther AM, Griffiths F. Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England. BMJ Open 2022; 12:e046189. [PMID: 35256437 PMCID: PMC8905976 DOI: 10.1136/bmjopen-2020-046189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations. OBJECTIVE This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen. DESIGN A multisited ethnographic study. SETTING Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England. PARTICIPANTS Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis. ANALYSIS Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases. RESULTS The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need. CONCLUSION Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mason B, Carduff E, Laidlaw S, Kendall M, Murray SA, Finucane A, Moine S, Kerssens J, Stoddart A, Tucker S, Haraldsdottir E, Ritchie SL, Fallon M, Keen J, Macpherson S, Moussa L, Boyd K. Integrating lived experiences of out-of-hours health services for people with palliative and end-of-life care needs with national datasets for people dying in Scotland in 2016: A mixed methods, multi-stage design. Palliat Med 2022; 36:478-488. [PMID: 35354412 PMCID: PMC8972951 DOI: 10.1177/02692163211066256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Unscheduled care is used increasingly during the last year of life by people known to have significant palliative care needs. AIM To document the frequency and patterns of use of unscheduled healthcare by people in their last year of life and understand the experiences and perspectives of patients, families and professionals about accessing unscheduled care out-of-hours. DESIGN A mixed methods, multi-stage study integrating a retrospective cohort analysis of unscheduled healthcare service use in the last year of life for all people dying in Scotland in 2016 with qualitative data from three regions involving service users, bereaved carers and general practitioners. SETTING Three contrasting Scottish Health Board regions and national datasets for the whole of Scotland. RESULTS People who died in Scotland in 2016 (n = 56,407) had 472,360 unscheduled contacts with one of five services: telephone advice, primary care, ambulance service, emergency department and emergency hospital admission. These formed 206,841 individual continuous unscheduled care pathways: 65% starting out-of-hours. When accessing healthcare out-of-hours, patients and carers prioritised safety and a timely response. Their choice of which service to contact was informed by perceptions and previous experiences of potential delays and whether the outcome might be hospital admission. Professionals found it difficult to practice palliative care in a crisis unless the patient had previously been identified. CONCLUSION Strengthening unscheduled care in the community, together with patient and public information about how to access these services could prevent hospital admissions of low benefit and enhance community support for people living with advanced illness.
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Affiliation(s)
- Bruce Mason
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | | | - Marilyn Kendall
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Anne Finucane
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Sebastien Moine
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Joannes Kerssens
- Electronic Data Research & Innovation Service (eDRIS), Public Health Scotland, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, The University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Stella Macpherson
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Lane ND, Gillespie SM, Steer J, Bourke SC. Uptake of Clinical Prognostic Tools in COPD Exacerbations Requiring Hospitalisation. COPD 2021; 18:406-410. [PMID: 34355632 DOI: 10.1080/15412555.2021.1959540] [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: 10/20/2022]
Abstract
Clinical prognostic tools are used to objectively predict outcomes in many fields of medicine. Whilst over 400 have been developed for use in chronic obstructive pulmonary disease (COPD), only a minority have undergone full external validation and just one, the DECAF score, has undergone an implementation study supporting use in clinical practice. Little is known about how such tools are used in the UK. We distributed surveys at two time points, in 2017 and 2019, to hospitals included in the Royal College of Physicians of London national COPD secondary care audit program. The survey assessed the use of prognostic tools in routine care of hospitalized COPD patients. Hospital response rates were 71/196 in 2017 and 72/196 in 2019. The use of the DECAF and PEARL scores more than doubled in decisions about unsupported discharge (7%-15.3%), admission avoidance (8.1%-17%) and readmission avoidance (4.8%-13.1%); it more than tripled (8.8%-27.8%) in decisions around hospital-at-home or early supported discharge schemes. In other areas, routine use of clinical prognostic tools was uncommon. In palliative care decisions, the use of the Gold Standards Framework Prognostic Indicator Guidance fell (5.6%-1.4%). In 2017, 43.7% of hospitals used at least one clinical prognostic tool in routine COPD care, increasing to 52.1% in 2019. Such tools can help challenge prognostic pessimism and improve care. To integrate these further into routine clinical care, future research should explore current barriers to their use and focus on implementation studies.Supplemental data for this article is available online at https://dx.doi.org/10.1080/15412555.2021.1959540.
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Affiliation(s)
- Nicholas D Lane
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah M Gillespie
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John Steer
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C Bourke
- Northumbria Healthcare NHS Foundation Trust, Research and Development, North Tyneside General Hospital, Rake Lane, North Shields, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Eli K, Hawkes CA, Fritz Z, Griffin J, Huxley CJ, Perkins GD, Wilkinson A, Griffiths F, Slowther AM. Assessing the quality of ReSPECT documentation using an accountability for reasonableness framework. Resusc Plus 2021; 7:100145. [PMID: 34382025 PMCID: PMC8340300 DOI: 10.1016/j.resplu.2021.100145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which supports the ReSPECT process, is designed to prompt clinicians to discuss wider emergency treatment options with patients and to structure the documentation of decision-making for greater transparency. Methods Following an accountability for reasonableness framework (AFR), we analysed 141 completed ReSPECT forms (versions 1.0 and 2.0), collected from six National Health Service (NHS) hospitals in England during the early adoption of ReSPECT. Structured through an evaluation tool developed for this study, the analysis assessed the extent to which the records reflected consistency, transparency, and ethical justification of decision-making. Results Recommendations relating to CPR were consistently recorded on all forms and were contextualised within other treatment recommendations in most forms. The level of detail provided about treatment recommendations varied widely and reasons for treatment recommendations were rarely documented. Patient capacity, patient priorities and preferences, and the involvement of patients/relatives in ReSPECT conversations were recorded in some, but not all, forms. Clinicians almost never documented their weighing of potential burdens and benefits of treatments on the ReSPECT forms. Conclusion In most ReSPECT forms, CPR recommendations were captured alongside other treatment recommendations. However, ReSPECT form design and associated training should be modified to address inconsistencies in form completion. These modifications should emphasise the recording of patient values and preferences, assessment of patient capacity, and clinical reasoning processes, thereby putting patient/family involvement at the core of good clinical practice. Version 3.0 of ReSPECT responds to these issues.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, UK
| | | | - Zoë Fritz
- Cambridge University Hospitals NHS Foundation Trust, UK
| | | | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, UK.,University Hospitals Birmingham NHS Foundation Trust, UK
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Huxley CJ, Eli K, Hawkes CA, Perkins GD, George R, Griffiths F, Slowther AM. General practitioners' experiences of emergency care and treatment planning in England: a focus group study. BMC FAMILY PRACTICE 2021; 22:128. [PMID: 34167478 PMCID: PMC8224258 DOI: 10.1186/s12875-021-01486-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 06/07/2021] [Indexed: 11/21/2022]
Abstract
Background Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs’ experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. Methods We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. Results GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a ‘good death’ is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient’s preferences around death, and GPs’ lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. Conclusion Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01486-w.
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Affiliation(s)
- Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Claire A Hawkes
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Rob George
- St Christopher's Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK.
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Bell MDD. Does ReSPECT neutralise medical paternalism in end-of-life care? Resuscitation 2021; 162:423-425. [PMID: 33798626 DOI: 10.1016/j.resuscitation.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/01/2022]
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study. Resuscitation 2021; 162:343-350. [PMID: 33482270 DOI: 10.1016/j.resuscitation.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice. METHODS ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations. RESULTS Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach. CONCLUSIONS While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT's aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.
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Svantesson M, Griffiths F, White C, Bassford C, Slowther A. Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106672. [PMID: 33402429 PMCID: PMC8639921 DOI: 10.1136/medethics-2020-106672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Besides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit (ICU). METHODS Analysis using the 'Dilemma method' and 'wide reflective equilibrium', on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals. ETHICAL ANALYSIS Four moral questions and associated value conflicts were identified. (1) Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. (2) Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient's values conflicted with preventing short-term suffering and provision of security. (3) To what extent should the intensivist gain others' input? Professional independence versus a holistic approach to decision-making. (4) Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security (experienced in a holistic sense of physical and emotional security for patients) were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised. CONCLUSION Proactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis.
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Affiliation(s)
- Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Frances Griffiths
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
| | - Catherine White
- Patient and Public Representative, Trustee, ICUsteps - the Intensive Care Patient Support Charity, Coventry, UK
| | - Chris Bassford
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
| | - AnneMarie Slowther
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
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Mason B, Kerssens JJ, Stoddart A, Murray SA, Moine S, Finucane AM, Boyd K. Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets. BMJ Open 2020; 10:e041888. [PMID: 33234657 PMCID: PMC7684800 DOI: 10.1136/bmjopen-2020-041888] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life. DESIGN Retrospective cohort analysis of national datasets with application of standard UK costings. PARTICIPANTS AND SETTING All people who died in Scotland in 2016 aged 18 or older (N=56 407). MAIN OUTCOME MEASURES Frequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs. RESULTS 53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ2 (4)=1004, p<0.001) or primary care out-of-hours (62%) (χ2 (4)=1924,p<0.001) and have hospital admissions (88%) (χ2 (4)=2644, p<0.001). People with organ failure (79%) contacted the ambulance service most frequently (χ2 (4)=584, p<0.001). Demographic factors associated with more unscheduled care were older age, social deprivation, living in own home and dying of cancer. People dying with organ failure formed the largest group in the cohort and had the highest NHS costs as a group. The cost of providing services in the community was estimated at 3.9% of total unscheduled care costs despite handling most out-of-hours calls. CONCLUSIONS Over 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.
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Affiliation(s)
- Bruce Mason
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sébastien Moine
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
- Health Education and Practices Laboratory, University of Paris 13, Bobigny, France
| | - Anne M Finucane
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
- Policy and Research, Marie Curie Hospice, Edinburgh, UK
| | - Kirsty Boyd
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
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Batten JN, Blythe JA, Wieten S, Cotler MP, Kayser JB, Porter-Williamson K, Harman S, Dzeng E, Magnus D. Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study. BMJ Qual Saf 2020; 30:668-677. [PMID: 33082165 DOI: 10.1136/bmjqs-2020-011222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/01/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied. DESIGN AND METHODS Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences. RESULTS The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories. CONCLUSIONS There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
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Affiliation(s)
- Jason N Batten
- Department of Medicine, Stanford University, Stanford, California, USA .,Department of Anesthesia, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Wieten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Piven Cotler
- Department of Health Sciences, California State University Northridge, Northridge, California, USA
| | - Joshua B Kayser
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Karin Porter-Williamson
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Stephanie Harman
- Department of Medicine, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
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Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory. PLoS One 2020; 15:e0239181. [PMID: 32936837 PMCID: PMC7494119 DOI: 10.1371/journal.pone.0239181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/02/2020] [Indexed: 12/01/2022] Open
Abstract
Purpose To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation. Method Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multi-disciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources. Results Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to operationalise the concept of ‘risk of dying’ intervention eligibility criteria (2) integration relied on a ‘champion’ to drive participation and ensure sustainability; and (3) differing skills and confidence led to variable engagement with difficult conversations with patients and families about, for example, nearness to end of life. Opportunities for reflexive monitoring were not routinely embedded within the intervention. Reflections on the use of the AMBER care bundle from HPs and patients and families, including recommended modifications became evident through this NPT-driven analysis. Conclusion To be successfully normalised, new clinical practices, such as the AMBER care bundle, must be studied within the wider context in which they operate. NPT can be used to the aid identification of practical strategies to assist in normalisation of complex interventions where the focus of care is on clinical uncertainty in acute hospital settings.
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