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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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Char S, Prager K, Dugdale L, Fischkoff K. Surgeon Perspectives on Daily Presentation of Ethical Dilemmas: A Qualitative Study. J Am Coll Surg 2023; 237:751-761. [PMID: 37427844 DOI: 10.1097/xcs.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Surgeons encounter and navigate a unique set of ethical dilemmas. The American College of Surgeons (ACS) previously identified 6 core ethical issues central to the practice of surgery, but there have been no reports of the true range and complexity of ethical dilemmas encountered by surgeons in their daily practice. Qualitative research is well positioned to address this question. STUDY DESIGN We conducted in-depth interviews with attending surgeons across multiple surgical subspecialties at a large, urban, academic medical center asking them to describe the most common ethical dilemmas they encounter in day-to-day practice. Interviews were recorded, transcribed, and coded according to a grounded theory, inductive approach. RESULTS Thirty attending surgeons were interviewed, representing twelve different general surgery subspecialties. The majority of dilemmas identified pertained to 4 of the 6 ACS identified core ethical issues: professional obligations, competition of interests, truth telling, and end-of-life care. No participants described dilemmas relating to the themes of confidentiality or surrogate decision-making. Approximately one-third of participants identified ethical issues not well characterized by the ACS core principles, most often relating to the pressure to provide care that is not medically indicated. There was strong support for a formalized surgical ethics curriculum. CONCLUSIONS Although the ACS-defined core ethical issues in surgery appropriately captured many ethical dilemmas identified by participants, surgeons described several scenarios not well characterized by these themes. A dedicated surgical ethics curriculum may help to better equip surgeons to navigate the ethical dilemmas they are likely to face in practice.
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Affiliation(s)
- Steven Char
- From the Department of Surgery, Division of General Surgery (Chan, Fischkoff), Columbia University Medical Center, New York, NY
| | - Kenneth Prager
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (Prager), Columbia University Medical Center, New York, NY
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
| | - Lydia Dugdale
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
- Department of Medicine, Division of General Medicine (Dugdale), Columbia University Medical Center, New York, NY
| | - Katherine Fischkoff
- From the Department of Surgery, Division of General Surgery (Chan, Fischkoff), Columbia University Medical Center, New York, NY
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
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Aslakson RA, Rickerson E, Fahy B, Waterman B, Siden R, Colborn K, Smith S, Verano M, Lira I, Hollahan C, Siddiqi A, Johnson K, Chandrashekaran S, Harris E, Nudotor R, Baker J, Heidari SN, Poultsides G, Conca-Cheng AM, Cook Chapman A, Lessios AS, Holdsworth LM, Gustin J, Ejaz A, Pawlik T, Miller J, Morris AM, Tulsky JA, Lorenz K, Temel JS, Smith TJ, Johnston F. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2314660. [PMID: 37256623 PMCID: PMC10233417 DOI: 10.1001/jamanetworkopen.2023.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/31/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. Objective To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. Design, Setting, and Participants From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Intervention Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. Main Outcomes and Measures The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. Results In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). Conclusions and Relevance To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. Trial Registration ClinicalTrials.gov Identifier: NCT03611309.
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Affiliation(s)
- Rebecca A. Aslakson
- Department of Anesthesiology, Lerner College of Medicine at the University of Vermont, Burlington
| | - Elizabeth Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bridget Fahy
- Department of Surgery, Divisions of Surgical Oncology and Palliative Medicine, University of New Mexico, Albuquerque
| | - Brittany Waterman
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Rachel Siden
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Shelby Smith
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Mae Verano
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Isaac Lira
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Caroline Hollahan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amn Siddiqi
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Kemba Johnson
- Clinical Research Center, Ohio State University Wexner Medical Center, Columbus
| | | | - Elizabeth Harris
- Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Joshua Baker
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Shireen N. Heidari
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Anna Sophia Lessios
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Laura M. Holdsworth
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Jillian Gustin
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Timothy Pawlik
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Judi Miller
- Patient Family Advocate, Baltimore, Maryland
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Karl Lorenz
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
- VA Palo Alto Healthcare System, Palo Alto, California
| | - Jennifer S. Temel
- Department of Medicine, Division of Hematology/Oncology, MGH, Boston, Massachusetts
| | - Thomas J. Smith
- Departments of Medicine and Oncology, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Fabian Johnston
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
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Tong W, Murali KP, Fonseca LD, Blinderman CD, Shelton RC, Hua M. Interpersonal Conflict between Clinicians in the Delivery of Palliative and End-of-Life Care for Critically Ill Patients: A Secondary Qualitative Analysis. J Palliat Med 2022; 25:1501-1509. [PMID: 35363575 PMCID: PMC9529295 DOI: 10.1089/jpm.2021.0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Conflict between clinicians is prevalent within intensive care units (ICUs) and may hinder optimal delivery of care. However, little is known about the sources of interpersonal conflict and how it manifests within the context of palliative and end-of-life care delivery in ICUs. Objective: To characterize interpersonal conflict in the delivery of palliative care within ICUs. Design: Secondary thematic analysis using a deductive-inductive approach. We analyzed existing qualitative data that conducted semistructured interviews to examine factors associated with variable adoption of specialty palliative care in ICUs. Settings/Subjects: In the parent study, 36 participants were recruited from two urban academic medical centers in the United States, including ICU attendings (n = 17), ICU nurses (n = 11), ICU social workers (n = 1), and palliative care providers (n = 7). Measurements: Coders applied an existing framework of interpersonal conflict to guide initial coding and analysis, combined with a flexible inductive approach allowing new codes to emerge. Results: We characterized three properties of interpersonal conflict: disagreement, interference, and negative emotion. In the context of delivering palliative and end-of-life care for critically ill patients, "disagreement" centered around whether patients were appropriate for palliative care, which care plans should be prioritized, and how care should be delivered. "Interference" involved preventing palliative care consultation or goals-of-care discussions and hindering patient care. "Negative emotion" included occurrences of silencing or scolding, rudeness, anger, regret, ethical conflict, and grief. Conclusions: Our findings provide an in-depth understanding of interpersonal conflict within palliative and end-of-life care for critically ill patients. Further study is needed to understand how to prevent and resolve such conflicts.
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Affiliation(s)
- Wendy Tong
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Komal P. Murali
- School of Nursing, Columbia University, New York, New York, USA
| | - Laura D. Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Craig D. Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences and Columbia University Mailman School of Public Health, New York, New York, USA
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Ellis DI, Altan D, Chang DC. Failure and Rescue in Surgery-Surgical Covenant, Palliative Care, and Reimagining Quality. JAMA Surg 2022; 157:2796288. [PMID: 36103167 DOI: 10.1001/jamasurg.2022.3181] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
This Viewpoint discusses the pitfalls of failure-to-rescue metrics and importance of palliative care within surgical care.
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Affiliation(s)
- Danielle I Ellis
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Defne Altan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
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The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation. Jt Comm J Qual Patient Saf 2022; 48:280-286. [DOI: 10.1016/j.jcjq.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/18/2022]
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Benbenishty J, Ganz FD, Anstey MH, Barbosa-Camacho FJ, Bocci MG, Çizmeci EA, Dybwik K, Ingels C, Lautrette A, Miranda-Ackerman RC, Estebanez-Montiel B, Plowright C, Ricou B, Robertsen A, Sprung CL. Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study. Intensive Crit Care Nurs 2021; 68:103138. [PMID: 34750044 DOI: 10.1016/j.iccn.2021.103138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/12/2021] [Accepted: 08/30/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Comparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015. METHODOLOGY This was a prospective observational study of 22 European ICUs included in the ETHICUS-II and I. Data were collected as per the ETHICUS-I and ETHICUS-II protocols. Four questions within the ETHICUS protocols related to nurse involvement in end of life decision making were analyzed. This is a comparison of changes in nurse involvement in end of life decisions from 1999 to 2015. SETTING International e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient. SUBJECTS Intensive care physicians and nurses, no interventions were performed. MEASUREMENTS A 20 question survey was used to describe the decision making process, on what basis was the decision made, who was involved in the decision making process, and what precise decisions were made. RESULTS A total of 4592 cases from 22 centres are included. While there was more agreement between nurses and physicians in ETHICUS-I compared to ETHICUS-I, fewer discussions with nurses occurred in ETHICUS-II. The frequency of end of life decisions that were discussed with nurses decreased in all three regions between ETHICUS-I and ETHICUS-II. CONCLUSION Based on the results of the current study, nurses should be further encouraged to increase their involvement in end of life decision-making, especially those in southern Europe.
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Affiliation(s)
- Julie Benbenishty
- Hadassah Hebrew University Medical Center and School of Nursing, Israel.
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Israel.
| | - Matthew H Anstey
- Sir Charles Gairdner Hospital, Perth, Australia; School of Public Health, Curtin University, Perth, Australia; School of Medicine, University of Western Australia, Australia.
| | | | - Maria Grazia Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elif Ayşe Çizmeci
- University of Toronto, Faculty of Medicine, Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada; Uludağ University, Faculty of Medicine, Department of Anesthesiology and Intensive Care, Bursa, Turkey
| | - Knut Dybwik
- Intensive Care Unit, Nordland Hospital, Bodø, Nord University, Bodø, Norway
| | - Catherine Ingels
- University Hospital Gasthuisberg Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Herestraat 49, B-3000 Leuven, Belgium.
| | - Alexandre Lautrette
- Intensive Care Medicine, Gabriel-Montpied University Hospital, Clermont-Ferrand, France.
| | | | | | | | - Bara Ricou
- Intensive Care of Geneva, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva Hospital and University of Geneva, Switzerland.
| | - Annette Robertsen
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Oslo, Norway.
| | - Charles L Sprung
- Department of Intensive Care, Hadassah Hebrew University Medical Center, Israel.
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Cushman T, Waisel DB, Treggiari MM. The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective. Anesth Analg 2021; 133:663-675. [PMID: 34014183 DOI: 10.1213/ane.0000000000005559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
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Affiliation(s)
- Tera Cushman
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - David B Waisel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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Ethics Consultation in Surgical Specialties. HEC Forum 2021; 34:89-102. [PMID: 33674985 PMCID: PMC7934986 DOI: 10.1007/s10730-021-09447-7] [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] [Accepted: 02/10/2021] [Indexed: 11/24/2022]
Abstract
Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.
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Hugar LA, Wulff-Burchfield EM, Winzelberg GS, Jacobs BL, Davies BJ. Incorporating palliative care principles to improve patient care and quality of life in urologic oncology. Nat Rev Urol 2021; 18:623-635. [PMID: 34312530 PMCID: PMC8312356 DOI: 10.1038/s41585-021-00491-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/07/2023]
Abstract
Palliative care - specialized healthcare focused on improving quality of life for patients with serious illnesses - can help urologists to care for patients with unmet symptom, coping and communication needs. Society guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend incorporating palliative care into standard oncological care, based on multiple randomized trials demonstrating that it significantly improves physical well-being, patient satisfaction and goal concordant care. Misconceptions regarding the objective and ideal timing of palliative care are common; a key concept is that palliative care and treatments seeking to cure or prolong life are not mutually exclusive. Urologists are well positioned to champion the integration of palliative care into surgical urologic oncology and should be aware of palliative care guidelines, indications for palliative care use and how the field of urologic oncology can adopt best practices.
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Affiliation(s)
- Lee A. Hugar
- grid.468198.a0000 0000 9891 5233Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL USA
| | - Elizabeth M. Wulff-Burchfield
- grid.412016.00000 0001 2177 6375Medical Oncology Division and Palliative Care Division, Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS USA
| | - Gary S. Winzelberg
- grid.10698.360000000122483208UNC Palliative Care Program, Division of Geriatric Medicine, Department of Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC USA
| | - Bruce L. Jacobs
- grid.21925.3d0000 0004 1936 9000Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Benjamin J. Davies
- grid.21925.3d0000 0004 1936 9000Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
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Chatterjee K, Harrington S, Sexton K, Goyal A, Robertson RD, Corwin HL. Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013). Jt Comm J Qual Patient Saf 2020; 46:493-500. [PMID: 32414575 DOI: 10.1016/j.jcjq.2020.03.011] [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: 08/24/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours). METHODS National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS. RESULTS Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization. CONCLUSIONS Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.
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Arnold-Forster A. 'A small cemetery': death and dying in the contemporary British operating theatre. MEDICAL HUMANITIES 2020; 46:278-287. [PMID: 31345933 PMCID: PMC7476300 DOI: 10.1136/medhum-2019-011668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 06/10/2023]
Abstract
Surgeon Henry Marsh begins his autobiography, Do No Harm, with a quotation from the French practitioner René Leriche, "Every surgeon carries within himself a small cemetery, where from time to time he goes to pray-a place of bitterness and regret, where he must look for an explanation for his failures". This article uses memoirs and oral history interviews to enter the operating theatre and consider the contemporary history of surgeons' embodied experiences of patient death. It will argue that these experiences take an under-appreciated emotional toll on surgeons, but also that they are deployed as a narrative device through which surgeons construct their professional identity. Crucially, however, there is as much forgetting as remembering in their accounts, and the 'labour' of death has been increasingly shifted out of the operating theatre, off the surgeons' hands and into the laps of others. The emotional costs of surgical care remain understudied. Indeed, while many researchers agree that undergoing surgery can be a troubling emotional experience for the patient, less scholarly attention has been paid to the emotional demands performing surgery makes on surgical practitioners. Is detachment the modus operandi of the modern surgeon and if so, is it tenable in moments of emotional intensity-like patient death?
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Suwanabol PA, Vitous CA, Perumalswami CR, Li SH, Raja N, Dillon BR, Lee CW, Forman J, Silveira MJ. Surgery Residents' Experiences With Seriously-Ill and Dying Patients: An Opportunity to Improve Palliative and End-of-Life Care. JOURNAL OF SURGICAL EDUCATION 2020; 77:582-597. [PMID: 32063510 DOI: 10.1016/j.jsurg.2019.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/25/2019] [Accepted: 12/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services. DESIGN Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients. SETTING General surgery residency programs across the state of Michigan. PARTICIPANTS General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group. RESULTS Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture. CONCLUSIONS This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.
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Affiliation(s)
- Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Chithra R Perumalswami
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Sylvia H Li
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas Raja
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Christina W Lee
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jane Forman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management, Ann Arbor Veterans Affairs Health, Ann Arbor, Michigan
| | - Maria J Silveira
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Scally CP, Robinson K, Blumenthaler AN, Bruera E, Badgwell BD. Identifying Core Principles of Palliative Care Consultation in Surgical Patients and Potential Knowledge Gaps for Surgeons. J Am Coll Surg 2020; 231:179-185. [PMID: 32311465 DOI: 10.1016/j.jamcollsurg.2020.03.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative medicine is an important component of care for patients with advanced cancer. Previous studies demonstrated that surgeons tend to underuse palliative care in comparison with medical services. In addition, little is known about the specific use of palliative care services among surgical oncology practices. Therefore, we designed and performed this study to evaluate the use of palliative care in medical and surgical oncology patients. STUDY DESIGN A single-institution retrospective review of consecutive palliative care consultations within a large National Cancer Institute-designated comprehensive cancer center in 2016 to 2017 was conducted. RESULTS We analyzed 120 patients (60 surgical and 60 medical). Patient demographics in the 2 groups were similar. The surgical oncology patients were more likely to undergo consultation for advanced care planning (32% vs 13%; p = 0.02). Medical oncology patients were more likely to undergo consultation for pain management (97% vs 62%; p < 0.001). Symptom assessment scores for medical patients more frequently demonstrated dyspnea and malignancy-related pain than in surgical patients. Also, palliative care recommendations and interventions for surgical patients more frequently included end-of-life discussions and transfer to the inpatient palliative care unit. For medical oncology patients, recommendations more often included changes in pain and bowel regimen medication. In addition, despite more frequent consults for advanced care planning in the surgical patients, code status was changed to DNR more frequently in the medical patient cohort. CONCLUSIONS Surgical patients were less likely to undergo palliative care consultation for assistance with symptom management and more likely to undergo consultation for assistance with end-of-life discussions than were medical oncology patients. Advanced care planning and end-of-life discussions should be an area of focus in palliative care education for surgeons.
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Affiliation(s)
- Christopher P Scally
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristen Robinson
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alisa N Blumenthaler
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D Badgwell
- Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Clapp JT, Diraviam SP, Lane-Fall MB, Szymczak JE, Muralidharan M, Chung JJ, Gutsche JT, Curley MAQ, Berns JS, Fleisher LA. Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration. Am J Kidney Dis 2019; 75:61-71. [PMID: 31492489 DOI: 10.1053/j.ajkd.2019.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE Collaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today's ICUs. Although there is considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the 2 parties remain poorly understood. This article describes interactions between nephrology consultants and ICU teams in the academic medical setting. STUDY DESIGN Focused ethnography using semi-structured interviews and participant observation. SETTING & PARTICIPANTS Purposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation. ANALYTICAL APPROACH Interview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach. RESULTS Nephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care. LIMITATIONS Aspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined. CONCLUSIONS Differences in approach between internal medicine-trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.
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Affiliation(s)
- Justin T Clapp
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Sushmitha P Diraviam
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meghan B Lane-Fall
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Julia E Szymczak
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Madhavi Muralidharan
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jamison J Chung
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Martha A Q Curley
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey S Berns
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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16
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Aslakson RA, Chandrashekaran SV, Rickerson E, Fahy BN, Johnston FM, Miller JA, Conca-Cheng A, Wang S, Morris AM, Lorenz K, Temel JS, Smith TJ. A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC). J Palliat Med 2019; 22:44-57. [PMID: 31486730 PMCID: PMC7366274 DOI: 10.1089/jpm.2019.0130] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).
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Affiliation(s)
- Rebecca A. Aslakson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California
| | - Shivani V. Chandrashekaran
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
| | - Elizabeth Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bridget N. Fahy
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Fabian M. Johnston
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alison Conca-Cheng
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Suwei Wang
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
| | - Arden M. Morris
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, California
| | - Karl Lorenz
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | - Jennifer S. Temel
- Division of Hematology and Oncology, Department of Medicine, Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, Maryland
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Chan JCY, Gupta AK, Stewart S, Babidge W, McCulloch G, Worthington MG, Maddern GJ. "Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients. Ann Thorac Surg 2019; 108:1801-1806. [PMID: 31254505 DOI: 10.1016/j.athoracsur.2019.04.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/05/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery. METHODS We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach. RESULTS A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit. CONCLUSIONS Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.
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Affiliation(s)
- Justin C Y Chan
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.
| | - Aashray K Gupta
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Sasha Stewart
- Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, Australia
| | - Wendy Babidge
- Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, Australia
| | - Glenn McCulloch
- Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Adelaide, Australia
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18
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Aslakson RA, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Moore M, Bhamidipati A, Mora S, Miller J, Singh S, Swoboda SM, Pawlik TM, Weiss M, Volandes A, Smith TJ, Bridges JFP, Roter DL. Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial. J Palliat Med 2019; 22:764-772. [PMID: 30964385 DOI: 10.1089/jpm.2018.0209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Palliative Care Section, Department of Medicine, Stanford University School of Medicine, Stanford, California.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarina R Isenberg
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,4 Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Norah L Crossnohere
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison M Conca-Cheng
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Madeleine Moore
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Akshay Bhamidipati
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silvia Mora
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judith Miller
- 6 Patient/Family Member Co-Investigator, Ellicott City, Maryland
| | - Sarabdeep Singh
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra M Swoboda
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Weiss
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Angelo Volandes
- 9 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J Smith
- 10 Department of Oncology and Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - John F P Bridges
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Debra L Roter
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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19
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Gandesbery B, Dobbie K, Joyce E, Hoeksema L, Perez Protto S, Gorodeski EZ. Surgical Versus Medical Team Assignment and Secondary Palliative Care Services for Patients Dying in a Cardiac Hospital. Am J Hosp Palliat Care 2018; 36:316-320. [DOI: 10.1177/1049909118819462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Secondary palliative care (SPC) provides several benefits for patients with cardiovascular disease, but historically, it has been underutilized in this population. Prior research suggests a low rate of SPC consultation by surgical teams in general, but little is known about how surgical teams utilize SPC in the setting of severe cardiovascular disease. Aim: To determine if surgical team assignment affects the probability of SPC for inpatients dying of cardiovascular disease. Design: Retrospective, cohort study. Methods: We identified all inpatients at a large cardiac hospital who had anticipated death under the care of a cardiology, cardiac surgery, or vascular surgery team in 2016. Our primary outcome was referral to SPC, including palliative medicine consultation or inpatient hospice care. Informed by univariate analysis, we created a multivariable logistic regression model, the significance of which was assessed with the Wald test. Results: Two hundred thirty-seven patients were included in our analysis: 93 (39%) received SPC and 144 (61%) were “missed opportunities.” Secondary palliative care was less frequent in patients assigned to a surgical, versus medical, team (11% vs 47%, P < .001). On multivariate analysis, surgical versus medical team assignment was the strongest risk-adjusted predictor of SPC (odds ratio [OR]: 0.10, P < .001). Other predictors of SPC included do not resuscitate status on admission (OR: 14, P < .001), length of stay (OR = 1.05/day, P < .001), and having Medicare (OR = 3.9, P = .002). Conclusions: Primary inpatient care by a surgical team had a strong inverse relationship with SPC. This suggests a possible cultural barrier within surgical disciplines to SPC.
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20
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Suwanabol PA, Kanters AE, Reichstein AC, Wancata LM, Dossett LA, Rivet EB, Silveira MJ, Morris AM. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018; 55:1196-1215.e5. [PMID: 29221845 DOI: 10.1016/j.jpainsymman.2017.11.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear. OBJECTIVES We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients. METHODS We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings. RESULTS A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers. CONCLUSIONS Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
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Affiliation(s)
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari C Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wancata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily B Rivet
- Department of Surgery and Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maria J Silveira
- Department of Surgery, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California, USA
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21
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Isenberg SR, Crossnohere NL, Patel MI, Conca-Cheng A, Bridges JFP, Swoboda SM, Smith TJ, Pawlik TM, Weiss M, Volandes AE, Schuster A, Miller JA, Pastorini C, Roter DL, Aslakson RA. An advance care plan decision support video before major surgery: a patient- and family-centred approach. BMJ Support Palliat Care 2018; 8:229-236. [PMID: 29555812 DOI: 10.1136/bmjspcare-2017-001449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/29/2018] [Accepted: 02/07/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Video-based advanc care planning (ACP) tools have been studied in varied medical contexts; however, none have been developed for patients undergoing major surgery. Using a patient- and family-centredness approach, our objective was to implement human-centred design (HCD) to develop an ACP decision support video for patients and their family members when preparing for major surgery. DESIGN AND METHODS The study investigators partnered with surgical patients and their family members, surgeons and other health professionals to design an ACP decision support video using key HCD principles. Adapting Maguire's HCD stages from computer science to the surgical context, while also incorporating Elwyn et al's specifications for patient-oriented decision support tool development, we used a six-stage HCD process to develop the video: (1) plan HCD process; (2) specify where video will be used; (3) specify user and organisational requirements; (4) produce and test prototypes; (5) carry out user-based assessment; (6) field test with end users. RESULTS Over 450 stakeholders were engaged in the development process contributing to setting objectives, applying for funding, providing feedback on the storyboard and iterations of the decision tool video. Throughout the HCD process, stakeholders' opinions were compiled and conflicting approaches negotiated resulting in a tool that addressed stakeholders' concerns. CONCLUSIONS Our patient- and family-centred approach using HCD facilitated discussion and the ability to elicit and balance sometimes competing viewpoints. The early engagement of users and stakeholders throughout the development process may help to ensure tools address the stated needs of these individuals. TRIAL REGISTRATION NUMBER NCT02489799.
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Affiliation(s)
- Sarina R Isenberg
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Family and Community Medicine - Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada.,Division of Oncology, Stanford University School of Medicine, Stanford, California, USA.,Department of Anesthesiology, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Norah L Crossnohere
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Manali I Patel
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | | - Sandy M Swoboda
- Department of Medicine, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA.,Department of Oncology, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Thomas J Smith
- Department of Surgery, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy M Pawlik
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew Weiss
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angelo E Volandes
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne Schuster
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Patient/Family Member Co-investigator, Architecture by Design, Ellicott City, Maryland, USA.,Patient/Family Member Co-investigator, Baltimore, Maryland, USA
| | - Judith A Miller
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Carolyn Pastorini
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Debra L Roter
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca A Aslakson
- Patient/Family Member Co-investigator, Architecture by Design, Ellicott City, Maryland, USA
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Ledoux M, Tricou C, Roux M, Dreano-Hartz S, Ruer M, Filbet M. Cancer Patients Dying in the Intensive Care Units and Access to Palliative Care. J Palliat Med 2018; 21:689-693. [PMID: 29480751 DOI: 10.1089/jpm.2017.0415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In France, cancer has become the leading cause of death. Intensive care units (ICU) focus on survival, which may not be an appropriate setting to provide palliative care (PC) as needed by cancer patients and families. OBJECTIVE To describe the cancer patients who died in the ICU in 2010 in a French academic medical center. DESIGN Retrospective study Measurements: We reviewed medical records of all cancer patients who died in the ICU in 2010. The information collected from electronic medical records included patient sociodemographics and clinical characteristics, PC service referral, and the date of first contact with PC. RESULTS Among the 536 cancer patients who died in 2010, 42 (8%) died in the ICU. The cancers were hematological (21%), gastrointestinal (21%) and head and neck (21%). One patient had a PC referral versus 45% in the total population (p < 0.001) and the referral was the same day as the death. Eight (19%) patients had chemotherapy during their last month of life and 2 during the ICU hospitalization. Seventy-four per cent of patient admissions to the ICU related directly to malignancy. The mean time between diagnosis of cancer and death was 2.3 years (standard deviation, 4.4). CONCLUSIONS Our work highlights the need for early PC in the illness trajectory of cancer patients to prevent the transfer of dying patients to the ICU. More studies are needed to understand the decision making leading to such transfers.
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Affiliation(s)
- Mathilde Ledoux
- 1 Department of Palliative Care, Centre Hospitalier de Lyon-Sud , Hospices Civils de Lyon, Lyon, France .,2 Palliative Care Unit, L'Hôpital Nord Ouest , Trévoux, France
| | - Colombe Tricou
- 1 Department of Palliative Care, Centre Hospitalier de Lyon-Sud , Hospices Civils de Lyon, Lyon, France
| | - Maxime Roux
- 3 Department of Anesthesiology, L'Hôpital Nord Ouest , Villefranche sur Saône, France
| | - Soazic Dreano-Hartz
- 1 Department of Palliative Care, Centre Hospitalier de Lyon-Sud , Hospices Civils de Lyon, Lyon, France
| | - Murielle Ruer
- 1 Department of Palliative Care, Centre Hospitalier de Lyon-Sud , Hospices Civils de Lyon, Lyon, France
| | - Marilène Filbet
- 1 Department of Palliative Care, Centre Hospitalier de Lyon-Sud , Hospices Civils de Lyon, Lyon, France
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Dzeng E. Navigating the Liminal State Between Life and Death: Clinician Moral Distress and Uncertainty Regarding New Life-Sustaining Technologies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:22-25. [PMID: 28112618 PMCID: PMC5610135 DOI: 10.1080/15265161.2016.1265172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Lilley EJ, Gemunden SA, Kristo G, Changoor N, Scott JW, Rickerson E, Shimizu N, Salim A, Cooper Z. Utility of the "Surprise" Question in Predicting Survival among Older Patients with Acute Surgical Conditions. J Palliat Med 2016; 20:420-423. [PMID: 27802091 DOI: 10.1089/jpm.2016.0313] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The surprise question is a validated tool for identifying patients with increased risk of death within one year who could, therefore, benefit from palliative care. However, its utility in surgery is unknown. OBJECTIVE We sought to determine whether the surprise question predicted 12-month mortality in older emergency general surgery patients. DESIGN This was a prospective cohort study. SETTING/SUBJECTS Emergency general surgery attendings and surgical residents in or beyond their third year of training at a single tertiary care academic hospital from January to July 2014. MEASUREMENTS Surgeons responded to the surprise question within 72 hours of evaluating patients, ≥65 years, hospitalized with an acute surgical condition. Patient data, including demographic and clinical characteristics, were extracted from the medical record. Mortality within 12 months of initial evaluation was determined by using Social Security death data. RESULTS Ten attending surgeons and 18 surgical residents provided 163 responses to the surprise question for 119 patients: 60% of responses were "No, I would not be surprised" and 40% were "Yes, I would be surprised." A "No" response was associated with increased odds of death within 12 months in binary logistic regression (OR 4.8 [95% CI 2.1-11.1]). CONCLUSIONS The surprise question is a valuable tool for identifying older patients with higher risk of death, and it may be a useful screening criterion for older emergency general surgery patients who would benefit from palliative care evaluation.
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Affiliation(s)
- Elizabeth J Lilley
- 1 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.,2 Department of Surgery, Rutgers-Robert Wood Johnson Medical School , New Brunswick, New Jersey
| | - Sean A Gemunden
- 3 Surgical ICU Translational Research (STAR) Center , Brigham and Women's Hospital, Boston, Massachusetts
| | - Gentian Kristo
- 4 Department of Surgery, Newton-Wellesley Hospital , Newton, Massachusetts
| | - Navin Changoor
- 1 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.,5 Department of Surgery, Howard University College of Medicine , Washington, DC
| | - John W Scott
- 1 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.,6 Department of Surgery, Harvard Medical School, Brigham and Women's Hospital , Boston, Massachusetts
| | - Elizabeth Rickerson
- 7 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,8 Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute , Boston, Massachusetts
| | - Naomi Shimizu
- 6 Department of Surgery, Harvard Medical School, Brigham and Women's Hospital , Boston, Massachusetts
| | - Ali Salim
- 1 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.,3 Surgical ICU Translational Research (STAR) Center , Brigham and Women's Hospital, Boston, Massachusetts.,6 Department of Surgery, Harvard Medical School, Brigham and Women's Hospital , Boston, Massachusetts
| | - Zara Cooper
- 1 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.,3 Surgical ICU Translational Research (STAR) Center , Brigham and Women's Hospital, Boston, Massachusetts.,6 Department of Surgery, Harvard Medical School, Brigham and Women's Hospital , Boston, Massachusetts
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Abstract
Many seriously ill geriatric patients are at higher risk for perioperative morbidity and mortality, and incorporating proactive palliative care principles may be appropriate. Advanced care planning is a hallmark of palliative care in that it facilitates alignment of the goals of care between the patient and the health care team. When these goals conflict, perioperative dilemmas can occur. Anesthesiologists must overcome many cultural and religious barriers when managing the care of these patients. Palliative care is gaining ground in several perioperative populations where integration with certain patient groups has occurred. Geriatric anesthesiologists must be aware of how palliative care and hospice influence and enhance the care of elderly patients.
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Affiliation(s)
- Allen N Gustin
- Department of Anesthesiology, Stritch School of Medicine, Loyola University Medicine, 2160 South 1st Avenue, Building 103, Room-3102, Chicago, IL 60153, USA.
| | - Rebecca A Aslakson
- Department of Anesthesiology and Critical Care Medicine, Palliative Medicine Program at the Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, 1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA; Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, 1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA
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26
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Cauley CE, Block SD, Koritsanszky LA, Gass JD, Frydman JL, Nurudeen SM, Bernacki RE, Cooper Z. Surgeons' Perspectives on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergencies: A Qualitative Study. J Palliat Med 2016; 19:529-37. [PMID: 27105058 DOI: 10.1089/jpm.2015.0450] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise. CONCLUSIONS Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
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Affiliation(s)
- Christy E Cauley
- 1 Ariadne Labs , Boston, Massachusetts.,3 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Susan D Block
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,5 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts.,6 Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | | | | | | | - Suliat M Nurudeen
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Zara Cooper
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,8 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts
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27
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Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions. Ann Surg 2016; 263:1-6. [DOI: 10.1097/sla.0000000000001491] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Green AR, Boyd CM, Rickard J, Gomon R, Leff B. Attitudes of older adults with serious competing health risks toward their implantable cardioverter-defibrillators: a pilot study. BMC Geriatr 2015; 15:173. [PMID: 26700296 PMCID: PMC4690308 DOI: 10.1186/s12877-015-0173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/16/2015] [Indexed: 11/23/2022] Open
Abstract
Background In elderly heart failure patients, the survival benefit of implantable cardioverter-defibrillators (ICDs) may be attenuated due to competing health risks, and the risk of adverse outcomes magnified. Our objective was to examine older adults’ attitudes towards ICD implantation in the context of competing health risks, exploring the determinants of ICD decision-making among a group of patients who had faced the decision in the past. Methods Telephone survey with a qualitative component. Patients were age ≥70 with single- or dual-chamber ICDs from a single academic cardiac device clinic. Health status was assessed with the Vulnerable Elders Survey (VES-13). Responses to open-ended questions were transcribed verbatim; an “editing analysis” approach was used to extract themes. Results Forty-four ICD recipients participated (mean age 77.5 years). Nineteen participants (43 %) had VES-13 scores ≥3, indicating a 50 % likelihood of death or functional decline within 2 years. Twenty-one participants (48 %) had received prior ICD shocks. Forty participants (91 %) said they would “definitely” choose to get an ICD again in their current health. By and large, patients revealed a strong desire to extend life, expressed complete confidence in the lifesaving capabilities of their ICDs, and did not describe consideration of competing health risks. Conclusions In this pilot telephone survey with a qualitative component, nearly all older adults with ICDs would still choose to get an ICD despite high short-term risk of death or health deterioration. These findings suggest the need to partner more effectively with patients and families to decide how best to use medical technologies, particularly for older adults with competing risks.
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Affiliation(s)
- Ariel R Green
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - John Rickard
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Robert Gomon
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Bruce Leff
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA. .,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, USA.
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"It's Parallel Universes": An Analysis of Communication Between Surgeons and Intensivists. Crit Care Med 2015; 43:2147-54. [PMID: 26181222 DOI: 10.1097/ccm.0000000000001187] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication. DESIGN Qualitative interview study. An inductive data analysis approach was taken. SETTING Seven intensivist-led ICUs in four academic hospitals. SUBJECTS Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise. CONCLUSIONS Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU.
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Yu J, Brown D, Kodner IJ, Ray S. Looking beyond the crystal ball: An ethical dilemma in advance directive implementation in multidisciplinary patient care. Surgery 2015; 158:1389-94. [DOI: 10.1016/j.surg.2015.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Aslakson RA, Schuster ALR, Reardon J, Lynch T, Suarez-Cuervo C, Miller JA, Moldovan R, Johnston F, Anton B, Weiss M, Bridges JFP. Promoting perioperative advance care planning: a systematic review of advance care planning decision aids. J Comp Eff Res 2015; 4:615-50. [PMID: 26346494 DOI: 10.2217/cer.15.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Anne L R Schuster
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
| | - Jessica Reardon
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Thomas Lynch
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Catalina Suarez-Cuervo
- The Johns Hopkins Evidence-based Practice Center, Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Judith A Miller
- Patient/Family Member Co-investigator, Architecture by Design, Ellicott City, MD 21042, USA
| | - Rita Moldovan
- Department of Medicine Nursing, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Fabian Johnston
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Blair Anton
- William H. Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - John F P Bridges
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
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Salottolo K, Offner PJ, Orlando A, Slone DS, Mains CW, Carrick M, Bar-Or D. The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience. Scand J Trauma Resusc Emerg Med 2015; 23:9. [PMID: 25645242 PMCID: PMC4333154 DOI: 10.1186/s13049-015-0094-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/19/2015] [Indexed: 12/20/2022] Open
Abstract
Background Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients. Methods We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications). Results Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay. Conclusions Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristin Salottolo
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Patrick J Offner
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Alessandro Orlando
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Denetta S Slone
- Trauma Services Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Matthew Carrick
- Trauma Services Department, Medical Center of Plano, Plano, TX, 75075, USA.
| | - David Bar-Or
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
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Barnett MD, Williams BR, Tucker RO. Sudden Advanced Illness: An Emerging Concept Among Palliative Care and Surgical Critical Care Physicians. Am J Hosp Palliat Care 2014; 33:321-6. [PMID: 25548391 DOI: 10.1177/1049909114565108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed and occur earlier during hospitalization. This study explores the concept of sudden advanced illness (SAI) and its relevance to patients requiring Palliative and Surgical Critical Care. METHODS Semi-structured interviews were completed with 16 physicians, querying each about (1) definitional components, (2) illustrative cases, and (3) comfort with SAI. Analysis was done by grounded theory. RESULTS SAI was characterized as unforeseen, emerging abruptly and producing devastating injury, often in healthy, younger patients. There is (1) prognostic uncertainty, (2) loss of capacity, and (3) unprepared surrogate decision-making. Cases are emotionally-charged and often personal. CONCLUSION The emerging concept of SAI is important for understanding how Palliative Care can enhance care for this subset of patients.
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Affiliation(s)
- Michael D Barnett
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham-Birmingham, AL, USA Division of General Pediatrics and Adolescent Medicine, University of Alabama at Birmingham-Birmingham, AL, USA
| | - Beverly R Williams
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham-Birmingham, AL, USA Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center-Birmingham, AL, USA
| | - Rodney O Tucker
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham-Birmingham, AL, USA
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Amini A, Miura JT, Larrieux G, Tsai S, Turaga KK, Christians KK, Brasel KJ, Clark Gamblin T, Weissman DE, Nattinger AB, Johnston FM. Palliative Care Training in Surgical Oncology and Hepatobiliary Fellowships: A National Survey of the Fellows. Ann Surg Oncol 2014; 22:1761-7. [DOI: 10.1245/s10434-014-4226-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Indexed: 12/25/2022]
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Abstract
OBJECTIVES Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation. DATA SOURCES We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files. STUDY SELECTION Selected studies included all English-language articles concerning adult patients using the search terms 'intensive care' or 'critical care' with 'palliative care,' 'supportive care,' 'end-of-life care,' or 'ethics.' DATA EXTRACTION : After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus. DATA SYNTHESIS Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care. CONCLUSIONS Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures.
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Affiliation(s)
- Rebecca A Aslakson
- 1Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, MD. 2The Palliative Care Program at the Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA. 4Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Hernandez RA, Hevelone ND, Lopez L, Finlayson SRG, Chittenden E, Cooper Z. Racial variation in the use of life-sustaining treatments among patients who die after major elective surgery. Am J Surg 2014; 210:52-8. [PMID: 25465749 DOI: 10.1016/j.amjsurg.2014.08.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/06/2014] [Accepted: 08/18/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although various studies have documented increased life-sustaining treatments among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown. METHODS A retrospective cohort study using the Nationwide Inpatient Sample (2006 to 2011) examining patients older than 39 years who died after elective colectomy was performed. Primary predictor variable was race, and main outcome was the use of life-sustaining treatment. RESULTS In univariate analysis, significant differences existed in use of cardiopulmonary resuscitation (CPR; black, 35.9%; Hispanic, 29.0%; other, 24.5%; white, 11.7%; P = .002) and reintubation (Hispanic, 75.0%; other, 69.0%; black, 52.3%; white, 45.2%; P = .01). In multivariate analysis, black (odds ratio [OR], 3.67; P = .01) and Hispanic (OR, 4.21; P = .03) patients were more likely to have undergone CPR, and Hispanic patients (OR, 4.24; P = .01) were more likely to have been reintubated (reference: white). CONCLUSIONS Blacks and Hispanics had increased odds of experiencing CPR, and Hispanics were more likely to have been reintubated before death after a major elective operation. These variations may imply worse quality of death and increased associated costs.
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Affiliation(s)
- Roland A Hernandez
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nathanael D Hevelone
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Lenny Lopez
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA; Disparities Solutions Center, Massachusetts General Hospital, Boston, MA, USA; Department of General Medicine, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Samuel R G Finlayson
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eva Chittenden
- Division of Pain and Palliative Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
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Karlekar M, Collier B, Parish A, Olson L, Elasy T. Utilization and determinants of palliative care in the trauma intensive care unit: results of a national survey. Palliat Med 2014; 28:1062-8. [PMID: 24827834 DOI: 10.1177/0269216314534514] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a paucity of data evaluating utilization of palliative care in trauma intensive care units. AIM We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units. DESIGN Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care. SETTING/PARTICIPANTS A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma. RESULTS A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to board-certified palliative care physicians (χ(2) = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were "giving up" (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician. CONCLUSION Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services.
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Affiliation(s)
| | - Bryan Collier
- Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Abby Parish
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Lori Olson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Tom Elasy
- Vanderbilt University, Nashville, TN, USA
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An environmental scan of advance care planning decision AIDS for patients undergoing major surgery: a study protocol. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2014; 7:207-17. [PMID: 24469597 DOI: 10.1007/s40271-014-0046-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients who undergo major surgery are at risk for perioperative morbidity and mortality. It would be appropriate to initiate advance care planning with patients prior to surgery, but surgeons may experience difficulty initiating such conversations. Rather than focus on changing clinician behavior, advance care planning decision aids can be an innovative vehicle to motivate advance care planning among surgical patients and their families. OBJECTIVE The purpose of this paper is to describe a study protocol for conducting an environmental scan concerning advance care planning decision aids that may be relevant to patients undergoing high-risk surgery. METHODS/DESIGN This study will gather information from written or verbal data sources that incorporate professional and lay perspectives: a systematic review, a grey literature review, key informant interviews, and patient and family engagement. It is envisioned that this study will generate three outcomes: a synthesis of current evidence, a summary of gaps in knowledge, and a taxonomy of existing advance care planning decision aids. DISCUSSION This environmental scan will demonstrate principles of patient-centered outcomes research, and it will exemplify a pioneering approach for reviewing complex interventions. Anticipated limitations are that information will be gathered from a small sample of patients and families, and that potentially relevant information could also be missing from the environmental scan due to the inclusion/exclusion criteria. Outcomes from the environmental scan will inform future patient-centered research to develop and evaluate a new decision aid.
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Bruce CR, Allen NG, Fahy BN, Gordon HL, Suarez EE, Bruckner BA. Challenges in deactivating a total artificial heart for a patient with capacity. Chest 2014; 145:625-631. [PMID: 24590023 DOI: 10.1378/chest.13-1103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
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Affiliation(s)
- Courtenay R Bruce
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX.
| | - Nathan G Allen
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Bridget N Fahy
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX; Department of Surgery, Weill Cornell Medical College, Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX; Division of Palliative Medicine, The Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX
| | - Harvey L Gordon
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Erik E Suarez
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist DeBakey Heart and Vascular Center and JC Walter Jr Transplant Center, St. Luke's Episcopal Hospital, Houston, TX
| | - Brian A Bruckner
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Texas Heart Institute, St. Luke's Episcopal Hospital, Houston, TX
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It's big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations. Ann Surg 2014; 259:458-63. [PMID: 24253139 DOI: 10.1097/sla.0000000000000314] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To identify the processes, surgeons use to establish patient buy-in to postoperative treatments. BACKGROUND Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown. METHODS We used purposive sampling to identify 3 surgeons from different subspecialties who routinely perform high-risk operations at each of 3 distinct medical centers (Toronto, Ontario; Boston, Massachusetts; Madison, Wisconsin). We recorded preoperative conversations with 3 to 7 patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively. RESULTS Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is "big surgery" and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients' questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly. CONCLUSIONS Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients' desires for prolonged postoperative life support on the basis of these preoperative conversations alone.
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Vinatier I, Fiancette M, Lebert C, Henry-Lagarrigue M, Martin-Lefèvre L. Collégialité dans les décisions de limitation ou d’arrêt de traitement en réanimation. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0811-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Siddiqui S. Surgeons Take on End-of-Life Care. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n11p611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Schulz V, Novick RJ. The Distinct Role of Palliative Care in the Surgical Intensive Care Unit. Semin Cardiothorac Vasc Anesth 2013; 17:240-8. [DOI: 10.1177/1089253213506121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. Palliative care enhances the SICU team’s ability to recognize pain and distress; establish the patient’s wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation. Educational opportunities to improve end-of-life management skills are outlined. It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU. Palliative care can provide a significant, “value added” contribution to the care of seriously ill SICU patients.
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Abstract
PURPOSE OF REVIEW The present review addresses the question of whether perioperative futility can be defined. RECENT FINDINGS Although attempts have been made to define futility in medicine, all proposed definitions are inadequate and as a result there has been a shift to a procedural conflict de-escalation approach to addressing clinical questions of futility. Informed consent is central to the problem of deciding whether an operative procedure may be futile and the criteria for adequate consent by either a patient or surrogate decision-maker are reviewed. An adequately informed patient or surrogate may, nevertheless, desire to proceed with a procedure considered futile by some members of the medical team as a result of conflicting values. The basis for this and the 'economy of hope' in which extremely ill patients with few treatment options are invested, is explored. The particular role of the anesthesiologist in deciding whether an operative procedure may be futile is examined. Three potential positions are suggested: the anesthesiologist as service provider, consultant, or gatekeeper. SUMMARY The present review will provide anesthesiologists with critical insight into the historical scholarship and current recommended process to address questions of perioperative futility.
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Shah MN, Stoev IT, Sanford DE, Gao F, Santiago P, Jaques DP, Dacey RG. Are readmission rates on a neurosurgical service indicators of quality of care? J Neurosurg 2013; 119:1043-9. [PMID: 23621593 DOI: 10.3171/2013.3.jns121769] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service. METHODS A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively. RESULTS A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16-96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer status when comparing privately insured patients and those with public or no insurance (p = 0.09). CONCLUSIONS The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.
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Wilson ME, Rhudy LM, Ballinger BA, Tescher AN, Pickering BW, Gajic O. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med 2013; 39:1009-18. [DOI: 10.1007/s00134-013-2896-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 02/26/2013] [Indexed: 11/30/2022]
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Paul Olson TJ, Brasel KJ, Redmann AJ, Alexander GC, Schwarze ML. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg 2013; 148:29-35. [PMID: 23324837 DOI: 10.1001/jamasurgery.2013.403] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine surgeons' experiences of conflict with intensivists and nurses about goals of care for their postoperative patients. DESIGN Cross-sectional incentivized US mail-based survey. SETTING Private and academic surgical practices. PARTICIPANTS A total of 2100 vascular, neurologic, and cardiothoracic surgeons. MAIN OUTCOME MEASURES Surgeon-reported rates of conflict with intensivists and nurses about goals of care for patients with poor postsurgical outcomes. RESULTS The adjusted response rate was 55.6%. Forty-three percent of surgeons reported sometimes or always experiencing conflict about postoperative goals of care with intensivists, and 43% reported conflict with nurses. Younger surgeons reported higher rates of conflict than older surgeons with both intensivists (57% vs 32%; P = .001) and nurses (48% vs 33%; P = .001). Surgeons practicing in closed intensive care units reported more frequent conflict than those practicing in open intensive care units (60% vs 41%; P = .005). On multivariate analysis, the odds of reporting conflict with intensivists were 2.5 times higher for surgeons with fewer years of experience compared with their older colleagues (odds ratio, 2.5; 95% CI, 1.6-3.8) and 70% higher for reporting conflict with nurses (odds ratio, 1.7; 95% CI, 1.1-2.6). The odds of reporting conflict with intensivists about goals of postoperative care were 40% lower for surgeons who primarily managed their intensive care unit patients than for those who worked in a closed unit (odds ratio, 0.60; 95% CI, 0.40-0.96). CONCLUSIONS Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes. Higher rates of conflict are associated with less experience and working in a closed intensive care unit.
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Affiliation(s)
- Terrah J Paul Olson
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med 2013; 41:1-8. [PMID: 23222269 DOI: 10.1097/ccm.0b013e31826a4650] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high-risk operations. DESIGN Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life- supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with 1) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and 2) declining to operate on such patients. SETTING AND SUBJECTS U.S. mail-based survey of 2,100 cardiothoracic, vascular, and neurosurgeons. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The adjusted response rate was 56%. Nearly two thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life-supporting treatment were more than two-fold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 compared with those who believed it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3-3.2). CONCLUSIONS Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.
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Zambrano SC, Chur-Hansen A, Crawford GB. How Do Surgeons Experience and Cope with the Death and Dying of Their Patients? A Qualitative Study in the Context of Life-limiting Illnesses. World J Surg 2013; 37:935-44. [DOI: 10.1007/s00268-013-1948-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lamba S, Murphy P, McVicker S, Harris Smith J, Mosenthal AC. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012; 44:508-19. [PMID: 22765967 DOI: 10.1016/j.jpainsymman.2011.10.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/09/2011] [Accepted: 10/12/2011] [Indexed: 11/24/2022]
Abstract
CONTEXT Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care. OBJECTIVES We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients. METHODS Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected. RESULTS Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye." CONCLUSION Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.
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Affiliation(s)
- Sangeeta Lamba
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ 07103, USA
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