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Rocha Tardelli N, Neves Forte D, de Oliveira Vidal EI. Advance Care Planning in Brazil. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:43-49. [PMID: 37380546 DOI: 10.1016/j.zefq.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 06/30/2023]
Abstract
Brazil is a country of continental size marked by extreme social inequalities. Its regulation of Advance Directives (AD) was not enacted by law but within the scope of the norms that govern the relationships between patients and physicians, as a resolution of the Federal Medical Council without any specific requirement for notarization. Despite this innovative starting point, most of the debate regarding Advance Care Planning (ACP) in Brazil has been dominated by a legal transactional approach focused on making decisions in advance and the creation of AD. Yet, other novel ACP models have recently emerged in the country with a focus on the creation of a specific quality of relationship between patients, families, and physicians aiming at the facilitating future decision-making. Most of the education on ACP in Brazil happens in the context of palliative care courses. As such, most ACP conversations are performed within palliative care services or by healthcare professionals with training in that area. Hence, the scarce access to palliative care services in the country means that ACP is still rare and that those conversations usually happen late in the course of disease. The authors posit that the existing paternalistic healthcare culture is one of the most important barriers to ACP in Brazil and envision with great concern the risk that its combination with extreme health inequalities and the lack of healthcare professionals' education on shared decision-making could lead to the misuse of ACP as a form of coercive practice to reduce healthcare use by vulnerable populations.
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Affiliation(s)
- Natália Rocha Tardelli
- Geriatrics division, Internal Medicine Department, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil.
| | - Daniel Neves Forte
- Emergency Department, University of São Paulo (USP) Medical School, São Paulo, Brazil; Research and Teaching Institute, Sírio-Libanês Hospital, São Paulo, Brazil
| | - Edison Iglesias de Oliveira Vidal
- Geriatrics division, Internal Medicine Department, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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2
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White DB, Andersen SK. Conversations on Goals of Care With Hospitalized, Seriously Ill Patients. JAMA 2023; 329:2021-2022. [PMID: 37210664 DOI: 10.1001/jama.2023.8970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah K Andersen
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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3
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Mentzelopoulos SD, Couper K, Raffay V, Djakow J, Bossaert L. Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation. J Clin Med 2022; 11:jcm11144005. [PMID: 35887769 PMCID: PMC9316602 DOI: 10.3390/jcm11144005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023] Open
Abstract
Background: In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with “low” (i.e., average or lower) 2015 questionnaire domain scores. Methods: The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades. Results: Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1–3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2–5.0; p = 0.035); this improvement was driven by countries with “low” 2015 domain D scores. In countries with “low” 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4–10.6; p = 0.047). Conclusions: In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously “low” scores in the corresponding domains of the 2015 questionnaire.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675 Athens, Greece
- Correspondence: or ; Tel.: +30-697-530-4909; Fax: +30-213-204-3307
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham, NHS Foundation Trust, Birmingham B15 2TH, UK;
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus;
- Serbian Resuscitation Council, 21102 Novi Sad, Serbia
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, 26801 Hořovice, Czech Republic;
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Teno JM. Promoting Multifaceted Interventions for Care of the Seriously Ill and Dying. JAMA HEALTH FORUM 2022; 3:e221113. [DOI: 10.1001/jamahealthforum.2022.1113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joan M. Teno
- School of Medicine, Oregon Health & Science University, Portland
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Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
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Lin AL, Newgard C, Caughey AB, Malveau S, Dotson A, Eckstrom E. End-of-Life Orders, Resource Utilization, and Costs Among Injured Older Adults Requiring Emergency Services. J Gerontol A Biol Sci Med Sci 2021; 76:1686-1691. [PMID: 32914190 DOI: 10.1093/gerona/glaa230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services. METHODS This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias. RESULTS We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2-2.6]; comfort OR, 2.0 [95% CI: 1.3-3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041-34,756]; limited interventions, $18,729 [95% CI: 12,913-24,545]; and comfort $15,593 [95% CI: 12,091-19,095]). There were no significant associations for all other outcomes. CONCLUSIONS Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.
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Affiliation(s)
- Amber L Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Abby Dotson
- Oregon POLST Registry, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Elizabeth Eckstrom
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Baek SK, Kim HJ, Kwon JH, Lee HY, Won YW, Kim YJ, Baik S, Ryu H. Preparation and Practice of the Necessary Documents in Hospital for the "Act on Decision of Life-Sustaining Treatment for Patients at the End-of-Life". Cancer Res Treat 2021; 53:926-934. [PMID: 34082493 PMCID: PMC8524011 DOI: 10.4143/crt.2021.326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/01/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST. Materials and Methods We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms. Results The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively. Conclusion The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.
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Affiliation(s)
- Sun Kyung Baek
- Division of Hematology and Oncology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Preventive Medicine, Ulsan University College of Medicine, Seoul, Korea
| | - Jung Hye Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Chungnam, Korea
| | - Ha Yeon Lee
- Division of Hematology and Oncology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sujin Baik
- Korea National Institute for Bioethics Policy, Seoul, Korea
| | - Hyewon Ryu
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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10
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Tolle SW. Aligning POLST orders with wishes: Time to put evidence into practice. J Am Geriatr Soc 2021; 69:1801-1804. [PMID: 33826762 PMCID: PMC8360100 DOI: 10.1111/jgs.17150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University Center for Ethics in Health Care, Portland, Oregon, USA
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11
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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12
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Impact of advance care planning on dying in hospital: Evidence from urgent care records. PLoS One 2020; 15:e0242914. [PMID: 33296395 PMCID: PMC7725362 DOI: 10.1371/journal.pone.0242914] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/11/2020] [Indexed: 12/02/2022] Open
Abstract
Place of death is an important outcome of end-of-life care. Many people do not have the opportunity to express their wishes and die in their preferred place of death. Advance care planning (ACP) involves discussion, decisions and documentation about how an individual contemplates their future death. Recording end-of-life preferences gives patients a sense of control over their future. Coordinate My Care (CMC) is London’s largest electronic palliative care register designed to provide effective ACP, with information being shared with urgent care providers. The aim of this study is to explore determinants of dying in hospital. Understanding advance plans and their outcomes can help in understanding the potential effects that implementation of electronic palliative care registers can have on the end-of-life care provided. Retrospective observational cohort analysis included 21,231 individuals aged 18 or older with a Coordinate My Care plan who had died between March 2011 and July 2019 with recorded place of death. Logistic regression was used to explore demographic and end-of-life preference factors associated with hospital deaths. 22% of individuals died in hospital and 73% have achieved preferred place of death. Demographic characteristics and end-of-life preferences have impact on dying in hospital, with the latter having the strongest influence. The likelihood of in-hospital death is substantially higher in patients without documented preferred place of death (OR = 1.43, 95% CI 1.26–1.62, p<0.001), in those who prefer to die in hospital (OR = 2.30, 95% CI 1.60–3.30, p<0.001) and who prefer to be cared in hospital (OR = 2.77, 95% CI 1.94–3.96, p<0.001). “Not for resuscitation” individuals (OR = 0.43, 95% CI 0.37–0.50, p<0.001) and who preferred symptomatic treatment (OR = 0.36, 95% CI 0.33–0.40, p<0.001) had a lower likelihood of in-hospital death. Effective advance care planning is necessary for improved end-of-life outcomes and should be included in routine clinical care. Electronic palliative care registers could empower patients by embedding patients’ wishes and personal circumstances in their care plans that are accessible by urgent care providers.
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Abstract
PURPOSE/OBJECTIVES The end-of-life needs and desires of patients, whether it is related to a terminal illness or age-related end-of-life physiological function, can vary from patient to patient. Each dying patient's case should be approached in an individual and patient-centered fashion while supporting the dying patient's desired preferences related to end-of-life treatment. This serves to recognize the dying patient's individual rights related to self-determination of preserving his or her dignity during the end-of-life process. As the U.S. population continues to age at the fastest pace in history, it is vital for end-of-life patients and their family members, health care providers, and lawmakers to consider how health policy can drive legislation that supports the dying patient's right to express his or her dignity and own end-of-life desires related to aid-in-dying by allowing health care providers to legally provide physician-assisted health (PAD) and death with dignity (DD) the end-of-life care dying patients prefer. PRIMARY PRACTICE SETTING(S) Palliative, hospice, and long-term care. FINDINGS/CONCLUSIONS When state laws do not support a terminally ill person's ability to make his or her own end-of-life decisions based on his or her own preferences and desires related to PAD and dignity in dying, there can be moral conflictions with the existing ethical principles that can contribute to additional distress and anxiety in the terminally ill patient. Not allowing the terminally ill patient the legal right to choose his or her preferences and desires at the end of life goes against the freedom of the patient to choose. The aging population is growing quickly, and people are living longer, which means the frail elderly in their final stages of death due to multisystem organ failure might also desire to have the option of PAD that supports dignity in dying. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Case managers are an instrumental and integral part of the end-of-life care team. They are held to the same standard of practice as clinical care providers when it comes to promoting the biomedical ethical points autonomy, beneficence, nonmaleficence, justice, and fidelity. Following these ethical principles is critical for case managers to consider when supporting the desires and preferences of terminally ill patients. Case managers should be involved in all the patient-centered decision making for a terminally ill patient's desire for DD and PAD. It is critical for case managers to follow their organization's defined code of professional conduct as well their specific professional organization and professional certifying body's defined code of ethics and conduct despite their personal convictions.
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Lovadini GB, Fukushima FB, Schoueri JFL, Reis RD, Fonseca CGF, Rodriguez JJC, Coelho CS, Neves AF, Rodrigues AM, Marques MA, Bassett R, Steinberg KE, Moss AH, Vidal EIO. To What Extent Do Physician Orders for Life-Sustaining Treatment (POLST) Reflect Patients' Preferences for Care at the End of Life? J Am Med Dir Assoc 2020; 22:334-339.e2. [PMID: 33246840 DOI: 10.1016/j.jamda.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether medical orders within Physician Orders for Life-Sustaining Treatment (POLST) forms reflect patients' preferences for care at the end of life. DESIGN This cross-sectional study assessed the agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation performed by an independent researcher during a single episode of hospitalization. SETTING AND PARTICIPANTS Inpatients at a single public university hospital, aged 21 years or older, and for whom one of their attending physicians provided a negative answer to the following question: "Would I be surprised if this patient died in the next year?" Data collection occurred between October 2016 and September 2017. MEASURES Agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation was measured by kappa statistics. RESULTS Sixty-two patients were interviewed. Patients' median (interquartile range) age was 62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement in at least 1 medical order for life-sustaining treatment was found between POLST forms and the content of the independent advance care planning conversation. The kappa statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI): 0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially administered nutrition, 0.87 (95% CI: 0.75-0.98). CONCLUSIONS AND IMPLICATIONS The high level of agreement between medical orders in POLST forms and the documentation in an independent advance care planning conversation offers further support for the POLST paradigm. In addition, the finding that the agreement was not 100% underscores the need to confirm frequently that POLST medical orders accurately reflect patients' current values and preferences of care.
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Affiliation(s)
- Gustavo B Lovadini
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Fernanda B Fukushima
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Joao F L Schoueri
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Roberto Dos Reis
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Cecilia G F Fonseca
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Jahaira J C Rodriguez
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Cauana S Coelho
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Adriele F Neves
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Aniela M Rodrigues
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Marina A Marques
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Rick Bassett
- Center for Nursing Excellence, St Luke's Health System, Boise, ID, USA
| | - Karl E Steinberg
- California State University, Institute for Palliative Care, Oceanside, CA, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University, Morgantown, WV, USA
| | - Edison I O Vidal
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil.
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Tolle SW, Jimenez VM, Eckstrom E. Reply to Artificial Nutrition Belongs on POLST. J Am Geriatr Soc 2019; 67:1987-1989. [PMID: 31412134 DOI: 10.1111/jgs.16090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 06/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Valerie M Jimenez
- Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Eckstrom
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
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Stretti F, Klinzing S, Ehlers U, Steiger P, Schuepbach R, Krones T, Brandi G. Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital. Anesth Analg 2019; 127:698-703. [PMID: 29649031 DOI: 10.1213/ane.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.
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Affiliation(s)
- Federica Stretti
- From the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | | | | | | | - Tanja Krones
- Clinical Ethics, University Hospital of Zurich, Zurich, Switzerland
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Abstract
Advanced care planning is a critically important part of the care of seriously and critically ill patients. A responsibility of all physicians as part of primary palliative care, advanced care planning discussions are more than discussions about code status and should begin early and proceed in parallel with recovery-focused care. Strategies and best practices for advanced care planning in the elective setting and when time is short are reviewed, as are the myriad legal documents that can be used to provide a physical representation of the advanced care planning discussions.
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Affiliation(s)
- Mackenzie R Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Mail Code L611, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department. Ann Emerg Med 2019; 75:171-180. [PMID: 31248675 DOI: 10.1016/j.annemergmed.2019.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
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DeMartino ES, Rolnick JA. The States as Laboratories: Regulation of Decisions for Incapacitated Patients. THE JOURNAL OF CLINICAL ETHICS 2019. [DOI: 10.1086/jce2019302089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Krones T, Budilivschi A, Karzig I, Otto T, Valeri F, Biller-Andorno N, Mitchell C, Loupatatzis B. Advance care planning for the severely ill in the hospital: a randomized trial. BMJ Support Palliat Care 2019; 12:bmjspcare-2017-001489. [PMID: 30665882 PMCID: PMC9380503 DOI: 10.1136/bmjspcare-2017-001489] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 06/25/2018] [Accepted: 07/25/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the impact of advance care planning (ACP) including decision aids for severely ill medical inpatients. METHODS Single-centre randomised controlled trial at a Swiss university hospital. Patients were randomly assigned (1:1) to receive an extra consultation with the hospital social service or a consultation with in-house facilitators trained according to an internationally established ACP programme. Trial participants with the exception of the observers were fully blinded. 115 competent severely ill adults, their surrogates and their attending physicians were enrolled and followed for 6 months after discharge or 3 months after death. The patient's wishes regarding resuscitation (primary outcome), last place of care and other end-of-life wishes were recorded. Knowledge and respect of the patient's wishes by the surrogates and attending physician were monitored. RESULTS Compared with controls, 6 months after the intervention, fewer patients wished to be resuscitated or were undecided (p=0.01), resuscitation wishes were documented more frequently (89% vs 64%, p=0.02) and surrogates and/or attending physicians had greater knowledge of the patient's wishes (62% vs 30%, p=0.01). Groups were not different with regard to wishes being fulfilled, with the exception of last place of care being achieved more frequently in the intervention group (29% vs 11 %, p=0.05). CONCLUSION ACP including decision aids offered to severely ill medical inpatients leads to greater knowledge, documentation and respect of treatment and end-of-life wishes. Introducing ACP to these patients however may be too late for many patients. Early integration of ACP during the illness trajectory and a broader regional approach may be more appropriate.
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Affiliation(s)
- Tanja Krones
- Head Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
| | - Ana Budilivschi
- Psychologist, Clinical Ethics, University Hospital Zürich, Zürich, Switzerland
| | - Isabelle Karzig
- Emergency specialist nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
| | - Theodore Otto
- Social Worker and Intensive Care Nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
| | - Fabio Valeri
- Statistician, Institute of Primary Care, University of Zürich, Zürich, Switzerland
| | - Nikola Biller-Andorno
- Director of the Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zürich, Switzerland
| | - Christine Mitchell
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Barbara Loupatatzis
- Palliative Care Physician, Palliative Care Unit, University Hospital Zürich, Zürich, Switzerland
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Abbott J. The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department. Ann Emerg Med 2018; 73:294-301. [PMID: 30503382 DOI: 10.1016/j.annemergmed.2018.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/06/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.
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Affiliation(s)
- Jean Abbott
- Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora, CO.
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Zive DM, Jimenez VM, Fromme EK, Tolle SW. Changes Over Time in the Oregon Physician Orders for Life-Sustaining Treatment Registry: A Study of Two Decedent Cohorts. J Palliat Med 2018; 22:500-507. [PMID: 30484728 PMCID: PMC6531902 DOI: 10.1089/jpm.2018.0446] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The Physician Orders for Life-Sustaining Treatment (POLST) began in Oregon in 1993 and has since spread nationally and internationally. Objectives: Describe and compare demographics and POLST orders in two decedent cohorts: deaths in 2010–2011 (Cohort 1) and in 2015–2016 (Cohort 2). Design: Descriptive retrospective study. Setting/Subjects: Oregon decedents with an active form in the Oregon POLST Registry. Measurements: Oregon death records were matched with POLST orders. Descriptive analysis and logistic regression models assess differences between the cohorts. Results: The proportion of Oregon decedents with a registered POLST increased by 46.6% from 30.9% (17,902/58,000) in Cohort 1 to 45.3% (29,694/65,458) in Cohort 2. The largest increase (83.3%) was seen in decedents 95 years or older with a corresponding 78.7% increase in those with Alzheimer's disease and dementia, while the interval between POLST form completion and death in these decedents increased from a median of 9–52 weeks. Although orders for do not resuscitate and other orders to limit treatment remained the most prevalent in both cohorts, logistic regression models confirm a nearly twofold increase in odds for cardiopulmonary resuscitation and full treatment orders in Cohort 2 when controlling for age, sex, race, education, and cause of death. Conclusion: Compared with Cohort 1, Cohort 2 reflected several trends: a 46.6% increase in POLST Registry utilization most marked in the oldest old, substantial increases in time from POLST completion to death, and disproportionate increases in orders for more aggressive life-sustaining treatment. Based on these findings, we recommend testing new criteria for POLST completion in frail elders.
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Affiliation(s)
- Dana M Zive
- 1 Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Valerie M Jimenez
- 2 Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
| | - Erik K Fromme
- 3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan W Tolle
- 4 Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health & Science University, Portland, Oregon
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Teno JM, Gozalo P, Trivedi AN, Bunker J, Lima J, Ogarek J, Mor V. Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015. JAMA 2018; 320:264-271. [PMID: 29946682 PMCID: PMC6076888 DOI: 10.1001/jama.2018.8981] [Citation(s) in RCA: 241] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care. OBJECTIVE To describe changes in site of death and patterns of care among Medicare decedents. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home. EXPOSURES Secular changes between 2000 and 2015. MAIN OUTCOMES AND MEASURES Medicare administrative data were used to determine site of death, place of care, health care transitions, which are changes in location of care, and burdensome patterns of care. Burdensome patterns of care were based on health care transitions during the last 3 days of life and multiple hospitalizations for infections or dehydration during the last 120 days of life. RESULTS The site of death and patterns of care were studied among 1 361 870 decedents who had Medicare fee-for-service (mean [SD] age, 82.8 [8.4] years; 58.7% female) and 871 845 decedents who had Medicare Advantage (mean [SD] age, 82.1 [8.5] years; 54.0% female). Among Medicare fee-for-service decedents, the proportion of deaths that occurred in an acute care hospital decreased from 32.6% (95% CI, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015, and deaths in a home or community setting that included assisted living facilities increased from 30.7% (95% CI, 30.6%-30.9%) in 2000 to 40.1% (95% CI, 39.9%-30.3% ) in 2015. Use of the intensive care unit during the last 30 days of life among Medicare fee-for-service decedents increased from 24.3% (95% CI, 24.1%-24.4%) in 2000 and then stabilized between 2009 and 2015 at 29.0% (95% CI, 28.8%-29.2%). Among Medicare fee-for-service decedents, health care transitions during the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) in 2000 to a high of 14.2% (95% CI, 14.0%-14.3%) in 2009 and then decreased to 10.8% (95% CI, 10.6%-10.9%) in 2015. The number of decedents enrolled in Medicare Advantage during the last 90 days of life increased from 358 600 in 2011 to 513 245 in 2015. Among decedents with Medicare Advantage, similar patterns in the rates for site of death, place of care, and health care transitions were observed. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, there was a lower likelihood of dying in an acute care hospital, an increase and then stabilization of intensive care unit use during the last month of life, and an increase and then decline in health care transitions during the last 3 days of life.
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Affiliation(s)
- Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Pedro Gozalo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Jennifer Bunker
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Julie Lima
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Jessica Ogarek
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
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Mentzelopoulos SD, Slowther AM, Fritz Z, Sandroni C, Xanthos T, Callaway C, Perkins GD, Newgard C, Ischaki E, Greif R, Kompanje E, Bossaert L. Ethical challenges in resuscitation. Intensive Care Med 2018; 44:703-716. [PMID: 29748717 DOI: 10.1007/s00134-018-5202-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/28/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE A rapidly evolving resuscitation science provides more effective treatments to an aging population with multiple comorbidites. Concurrently, emergency care has become patient-centered. This review aims to describe challenges associated with the application of key principles of bioethics in resuscitation and post-resuscitation care; propose actions to address these challenges; and highlight the need for evidence-based ethics and consensus on ethical principles interpretation. METHODS Following agreement on the article's outline, subgroups of 2-3 authors provided narrative reviews of ethical issues concerning autonomy and honesty, beneficence/nonmaleficence and dignity, justice, specific practices/circumstances such as family presence during resuscitation, and emergency research. Proposals for addressing ethical challenges were also offered. RESULTS Respect for patient autonomy can be realized through honest provision of information, shared decision-making, and advance directives/care planning. Essential prerequisites comprise public and specific healthcare professionals' education, appropriate regulatory provisions, and allocation of adequate resources. Regarding beneficence/nonmaleficence, resuscitation should benefit patients, while avoiding harm from futile interventions; pertinent practice should be based on neurological prognostication and patient/family-reported outcomes. Regarding dignity, aggressive life-sustaining treatments against patients preferences should be avoided. Contrary to the principle of justice, resuscitation quality may be affected by race/income status, age, ethnicity, comorbidity, and location (urban versus rural or country-specific/region-specific). Current evidence supports family presence during resuscitation. Regarding emergency research, autonomy should be respected without hindering scientific progress; furthermore, transparency of research conduct should be promoted and funding increased. CONCLUSIONS Major ethical challenges in resuscitation science need to be addressed through complex/resource-demanding interventions. Such actions require support by ongoing/future research.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Zoe Fritz
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Claudio Sandroni
- Istituto Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Fondazione Policlinico, Universitario Agostino Gemelli, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Theodoros Xanthos
- European University, Engomi, Cyprus.,President Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | | | - Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Craig Newgard
- Department of Emergency Medicine Oregon Health and Science University Portland, Center for Policy and Research in Emergency Medicine, Portland, OR, USA
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece
| | - Robert Greif
- Department of Anesthesiology and Pain Therapy, University of Bern, Bern University Hospital, 3010, Bern, Switzerland
| | - Erwin Kompanje
- Department of Intensive Care, Department of Ethics and Philosophy of Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Leo Bossaert
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,European Resuscitation Council, Niel, Belgium
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Hickman SE, Sudore RL, Sachs GA, Torke AM, Myers AL, Tang Q, Bakoyannis G, Hammes BJ. Use of the Physician Orders for Scope of Treatment Program in Indiana Nursing Homes. J Am Geriatr Soc 2018; 66:1096-1100. [PMID: 29566429 DOI: 10.1111/jgs.15338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/20/2018] [Accepted: 02/04/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the use of the Indiana Physician Orders for Scope of Treatment (POST) form to record nursing home (NH) resident treatment preferences and associated practices. DESIGN Survey. SETTING Indiana NHs. PARTICIPANTS Staff responsible for advance care planning in 535 NHs. MEASUREMENTS Survey about use of the Indiana POST, related policies, and educational activities. METHODS NHs were contacted by telephone or email. Nonresponders were sent a brief postcard survey. RESULTS Ninety-one percent (n=486) of Indiana NHs participated, and 79% had experience with POST. Of the 65% of NHs that complete POST with residents, 46% reported that half or more residents had a POST form. POST was most often completed at the time of admission (68%). Only 52% of participants were aware of an existing facility policy regarding use of POST; 80% reported general staff education on POST. In the 172 NHs not using POST, reasons for not using it included unfamiliarity with the tool (23%) and lack of facility policies (21%). CONCLUSION Almost 3 years after a grassroots campaign to introduce the voluntary Indiana POST program, a majority of NHs were using POST to support resident care. Areas for improvement include creating policies on POST for all NHs, training staff on POST conversations, and considering processes that may enhance the POST conversation, such as finding an optimal time to engage in conversations about treatment preferences other than a potentially rushed admission process.
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Affiliation(s)
- Susan E Hickman
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana.,Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
| | - Rebecca L Sudore
- School of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California
| | - Greg A Sachs
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana, Indianapolis, Indiana
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana, Indianapolis, Indiana
| | - Anne L Myers
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
| | - Qing Tang
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Giorgos Bakoyannis
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin
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27
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Hecht K, Krones T, Otto T, Karzig-Roduner I, Loupatatzis B. [Advance Care Planning in Swiss Nursing Homes: Results of a Focus Group Study]. PRAXIS 2018; 107:1085-1092. [PMID: 30278843 DOI: 10.1024/1661-8157/a003101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Advance Care Planning in Swiss Nursing Homes: Results of a Focus Group Study Abstract. Advance Care Planning (ACP) is a standardized consultation process in which patients define their therapy goals for future medical treatments with the help of a qualified health care facilitator. This way, ACP increases the probability that patients' wishes are fulfilled in case of decisional incapacity. The aim of this study was to implement a previously tested Swiss ACP program in two Swiss nursing homes to better understand the resulting processes, chances and difficulties. For this purpose focus group interviews were conducted after first implementation steps. The results show that an ACP implementation needs and must be coordinated with an approach covering the entire health system.
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Sathitratanacheewin S, Engelberg RA, Downey L, Lee RY, Fausto JA, Starks H, Dunlap B, Sibley J, Lober W, Loggers ET, Khandelwal N, Curtis JR. Temporal Trends Between 2010 and 2015 in Intensity of Care at End-of-Life for Patients With Chronic Illness: Influence of Age Under vs. Over 65 Years. J Pain Symptom Manage 2018; 55:75-81. [PMID: 28887270 PMCID: PMC5734983 DOI: 10.1016/j.jpainsymman.2017.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT Recent analyses of Medicare data show decreases over time in intensity of end-of-life care. Few studies exist regarding trends in intensity of end-of-life care for those under 65 years of age. OBJECTIVES To examine recent temporal trends in place of death, and both hospital and intensive care unit (ICU) utilization, for age-stratified decedents with chronic, life-limiting diagnoses (<65 vs. ≥65 years) who received care in a large healthcare system. METHODS Retrospective cohort using death certificates and electronic health records for 22,068 patients with chronic illnesses who died between 2010 and 2015. We examined utilization overall and stratified by age using multiple regression. RESULTS The proportion of deaths at home did not change, but hospital admissions in the last 30 days of life decreased significantly from 2010 to 2015 (hospital b = -0.026; CI = -0.041, -0.012). ICU admissions in the last 30 days also declined over time for the full sample and for patients aged 65 years or older (overall b = -0.023; CI = -0.039, -0.007), but was not significant for younger decedents. Length of stay (LOS) did not decrease for those using the hospital or ICU. CONCLUSION From 2010 to 2015, we observed a decrease in hospital admissions for all age groups and in ICU admissions for those over 65 years. As there were no changes in the proportion of patients with chronic illness who died at home nor in hospital or ICU LOS in the last 30 days, hospital and ICU admissions in the last 30 days may be a more responsive quality metric than site of death or LOS for palliative care interventions.
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Affiliation(s)
- Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James A Fausto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Helene Starks
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Ben Dunlap
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - William Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Seattle Cancer Care Alliance, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA.
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Sanders JJ, Curtis JR, Tulsky JA. Achieving Goal-Concordant Care: A Conceptual Model and Approach to Measuring Serious Illness Communication and Its Impact. J Palliat Med 2017; 21:S17-S27. [PMID: 29091522 DOI: 10.1089/jpm.2017.0459] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High-quality care for seriously ill patients aligns treatment with their goals and values. Failure to achieve "goal-concordant" care is a medical error that can harm patients and families. Because communication between clinicians and patients enables goal concordance and also affects the illness experience in its own right, healthcare systems should endeavor to measure communication and its outcomes as a quality assessment. Yet, little consensus exists on what should be measured and by which methods. OBJECTIVES To propose measurement priorities for serious illness communication and its anticipated outcomes, including goal-concordant care. METHODS We completed a narrative review of the literature to identify links between serious illness communication, goal-concordant care, and other outcomes. We used this review to identify gaps and opportunities for quality measurement in serious illness communication. RESULTS Our conceptual model describes the relationship between communication, goal-concordant care, and other relevant outcomes. Implementation-ready measures to assess the quality of serious illness communication and care include (1) the timing and setting of serious illness communication, (2) patient experience of communication and care, and (3) caregiver bereavement surveys that include assessment of perceived goal concordance of care. Future measurement priorities include direct assessment of communication quality, prospective patient or family assessment of care concordance with goals, and assessment of the bereaved caregiver experience. CONCLUSION Improving serious illness care necessitates ensuring that high-quality communication has occurred and measuring its impact. Measuring patient experience and receipt of goal-concordant care should be our highest priority. We have the tools to measure both.
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Affiliation(s)
- Justin J Sanders
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,3 Ariadne Labs , Boston, Massachusetts
| | - J Randall Curtis
- 4 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - James A Tulsky
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
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Moss AH, Zive DM, Falkenstine EC, Dunithan C. The Quality of POLST Completion to Guide Treatment: A 2-State Study. J Am Med Dir Assoc 2017; 18:810.e5-810.e9. [PMID: 28668665 DOI: 10.1016/j.jamda.2017.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Physician Orders for Life-Sustaining Treatment (POLST) need to be complete and consistent to allow health care personnel to honor patient preferences in a time of emergency. The purpose of our study was to evaluate the quality of POLST completion to guide treatment for level of medical intervention. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study combined data from the Oregon and West Virginia POLST registries for the study period January 1, 2010, through December 31, 2016. All POLST form resuscitation (section A) and level of medical intervention (section B) orders were reviewed. MEASUREMENTS Percent of POLST form orders in sections A and B with and without contradictions. RESULTS During the study period, there were 268,386 POLST forms in the Oregon POLST Registry and 10,122 forms in the West Virginia e-Directive Registry. Of the forms, 99.2% in Oregon and 96.6% in West Virginia contained orders in both sections A and B. There were contradictions on 0.11% of forms from Oregon and 2.53% from West Virginia. CONCLUSIONS The quality of POLST form completion in the Oregon and West Virginia registries is good with less than 10% of forms lacking orders in sections A and B and containing contradictory orders. This study indicates what type of results are possible with statewide education, likely through POLST Paradigm Programs. Further research is needed to determine the quality of POLST form completion in other states and other factors that contribute to their quality.
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Affiliation(s)
- Alvin H Moss
- Center for Health Ethics and Law, West Virginia University, Morgantown, WV.
| | - Dana M Zive
- Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, OR
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Tolle SW, Teno JM. Lessons from End-of-Life Care in Oregon. N Engl J Med 2017; 376:2096. [PMID: 28538135 DOI: 10.1056/nejmc1704727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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