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Coyle A, Bhatia S, Reyes Arnaldy A, Wang K, Lindenberger EC, Fishman M. Advance care planning clinic: A structured clinical experience for internal medicine residents. J Am Geriatr Soc 2021; 69:2931-2938. [PMID: 34374990 DOI: 10.1111/jgs.17411] [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: 03/09/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Advance care planning (ACP) is an important step to provide medical care consistent with patients' preferences and values. Nationally, rates of ACP completion are low, and internal medicine residency clinics face additional barriers. To address this need, we implemented an ACP clinic for internal medicine residents. METHODS An ACP clinical experience was created for PGY2 residents beginning in 2018, with 6 total sessions, consisting of consolidated didactics, protected time to identify, outreach, and schedule patients, and two half days of dedicated ACP visits. Residents were surveyed before (end of PGY1) and after (end of PGY2) the intervention. The preceding residency class, serving as a historic control, only received the curriculum and were surveyed at the end of their PGY2 year. Electronic medical record (EMR) data was accessed to track ACP documentation. RESULTS The overall survey response rate was 124/134 (93%). Comparing the intervention cohort before and after the intervention, there was a significant increase in self-assessed confidence in completing ACP (2.1/4.0 vs 3.5/4.0, p < 0.01). Comparing the intervention and historic cohorts (end of PGY2), the intervention was associated with improved confidence in ability to complete ACP for their patients (3.5/4.0 vs 2.7/4.0, p < 0.01). The historic control had no increase in ACP documentation rates over time, while the intervention cohort had a 13.9% absolute increase in ACP documentation for their patients over the course of residency (p < 0.01). CONCLUSION The creation of an ACP-specific clinical experience, in conjunction with existing curricula, resulted in significant improvements in knowledge, self-assessed skills and behavior, and EMR documentation.
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Affiliation(s)
- Andrew Coyle
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sonica Bhatia
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Katherine Wang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth C Lindenberger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Mary Fishman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Sterie A, Jones L, Jox RJ, Truchard ER. 'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions. Health Expect 2021; 24:790-799. [PMID: 33682993 PMCID: PMC8235896 DOI: 10.1111/hex.13212] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. OBJECTIVE The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. METHOD We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. RESULTS Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. DISCUSSION AND CONCLUSIONS The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care. PATIENT CONTRIBUTION Patients were involved in the data collection stage of the study.
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Affiliation(s)
- Anca‐Cristina Sterie
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Laura Jones
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Ralf J. Jox
- Palliative and Supportive Care ServiceChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
- Institute of Humanities in MedicineLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Eve Rubli Truchard
- Service of Geriatrics and Geriatric RehabilitationChair of Geriatric Palliative CareLausanne University Hospital and University of LausanneLausanneSwitzerland
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Zenasni Z, Reynolds EC, Harrison DA, Rowan KM, Nolan JP, Soar J, Smith GB. The impact of the Tracey judgment on the rates and outcomes of in-hospital cardiac arrests in UK hospitals participating in the National Cardiac Arrest Audit. Clin Med (Lond) 2020; 20:319-323. [PMID: 32414723 DOI: 10.7861/clinmed.2019-0454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile. METHOD Using UK National Cardiac Arrest Audit data, the IHCA rate and proportion of resuscitation attempts deemed futile were compared for two periods (pre-judgment (01 July 2012 - 16 June 2014, inclusive) and post-judgment (01 July 2014 - 30 June 2016, inclusive)) using interrupted time series analyses. RESULTS A total of 43,109 IHCAs (115 hospitals) were analysed. There were fewer IHCAs post- than pre-judgment (21,324 vs 21,785, respectively). The IHCA rate was declining over time before the judgment but there was an abrupt and statistically significant increase in the period immediately following the judgment (p<0.001). This was not sustained post-judgment. The proportion of resuscitation attempts deemed futile was smaller post-judgment than pre-judgment (8.2% vs 14.9%, respectively). The rate of attempts deemed futile decreased post-judgment (p<0.001). CONCLUSION The IHCA rate increased immediately after the Tracey judgment while the proportion of resuscitation attempts deemed futile decreased. The precise mechanisms for these changes are unclear.
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Affiliation(s)
- Zohra Zenasni
- Intensive Care National Audit & Research Centre, London, UK
| | | | | | | | - Jerry P Nolan
- University of Warwick, Warwick, UK and consultant in anaesthesia and intensive care medicine, Royal United Hospital, Bath, UK
| | | | - Gary B Smith
- Bournemouth University, Bournemouth, UK; on behalf of the National Cardiac Arrest Audit
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Alsaati BA, Aljishi MN, Alshamakh SS, Banjar NS, Basharaheel HA, Alamri RS. The Concept of Do Not Resuscitate for Students in King Abdulaziz University Hospital. Indian J Palliat Care 2019; 25:544-549. [PMID: 31673210 PMCID: PMC6812427 DOI: 10.4103/ijpc.ijpc_78_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Do not resuscitate (DNR) is a medical procedure for patients who are suffering from critical, untreatable, and irreversible disease where the patient's life is predicted to end. DNR is considered a sensitive decision for patients and their relatives, as well as physicians. Aim: This study is aimed to assess the knowledge and attitude of medical students and interns toward the DNR order and the factors affecting their attitude at the King Abdulaziz University Hospital (KAUH) in Jeddah. Methods: Nonintervention cross-sectional study was conducted among 429 medical students (preclinical and clinical years) and interns who were given an online questionnaire between May and June in 2016 at KAUH in 18 Kingdom of Saudi Arabia. Results: Our study indicates that most of the participants (73.2%) were familiar with DNR order; however, more than half of them (58.3%) did not take any lecture or session on DNR. Large proportion of medical students had the opinion that attending a lecture or session on DNR would help them discuss it more skillfully with the patients and their relatives. More than half of the participants (55%) believed that there is a Fatwa that regulates DNR on the Islamic level. Conclusion: Participants, who were interns, were more familiar with the term DNR, whereas the 2nd-year medical students were less familiar with DNR. Considering the variation in the knowledge of participants about DNR, we conclude that additional lectures and sessions about DNR should be added to the medical school curriculum to make the students more confident and able in handling the DNR discussions.
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Affiliation(s)
| | - Maram Nader Aljishi
- Department of Medical Students, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sunds Salah Alshamakh
- Department of Medical Students, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nujood Salah Banjar
- Department of Medical Students, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hadeel Ahmed Basharaheel
- Department of Medical Students, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rawan Saleh Alamri
- Department of Medical Students, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Medical students’ knowledge and feeling about end-of-life decisions: A national French survey. Anaesth Crit Care Pain Med 2018; 37:635-636. [DOI: 10.1016/j.accpm.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/20/2022]
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Vanderhaeghen B, Van Beek K, De Pril M, Bossuyt I, Menten J, Rober P. What do hospitalists experience as barriers and helpful factors for having ACP conversations? A systematic qualitative evidence synthesis. Perspect Public Health 2018; 139:97-105. [PMID: 30010486 DOI: 10.1177/1757913918786524] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Hospitalists seem to struggle with advance care planning implementation. One strategy to help them is to understand which barriers and helpful factors they may encounter. AIMS: This review aims to give an overview on what hospitalists experience as barriers and helpful factors for having advance care planning conversations. METHOD: A systematic synthesis of the qualitative literature was conducted. DATA SOURCES: A bibliographic search of English peer-reviewed publications in PubMed, Embase, CINAHL, Central, PsycINFO, and Web of Science was undertaken. RESULTS: Hospitalists report lacking communication skills which lead to difficulties with exploring values and wishes of patients, dealing with emotions of patients and families and approaching the conversation about letting a patient die. Other barriers are related to different interpretations of the concept advance care planning, cultural factors, like being lost in translation, and medicolegal factors, like fearing prosecution. Furthermore, hospitalists report that decision-making is often based on irrational convictions, and it is highly personal. Physician and patient characteristics, like moral convictions, experience, and personality play a role in the decision-making process. Hospitalists report that experience and learning from more experienced colleagues is helpful. Furthermore, efficient multidisciplinary co-operation is helping. CONCLUSION: This systematic review shows that barriers are often related to communication issues and the convictions of the involved hospitalist. However, they seem to be preventable by creating a culture where experienced professionals can be consulted, where convictions can be questioned, and where co-operation within and between organizations is encouraged. This knowledge can serve as a basis for implementation.
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Affiliation(s)
- Birgit Vanderhaeghen
- Palliative Support Team, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Karen Van Beek
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Mieke De Pril
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Inge Bossuyt
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Johan Menten
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Peter Rober
- UPC KU Leuven, Leuven, Belgium
- Institute for Family and Sexuality Studies, Department of Neurosciences, School of Medicine, KU Leuven, Leuven, Belgium
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Vanderhaeghen B, Bossuyt I, Opdebeeck S, Menten J, Rober P. Toward Hospital Implementation of Advance Care Planning: Should Hospital Professionals Be Involved? QUALITATIVE HEALTH RESEARCH 2018; 28:456-465. [PMID: 29059015 DOI: 10.1177/1049732317735834] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In Belgium, Advance Care Planning (ACP) is not well implemented in hospital practice. One of the premises for successful implementation is involving the adopters in the implementation process. In hospital, important adopters of ACP are physicians, nurses, social workers, and psychologists. First, this study wants to understand what the characteristics are of ACP in hospital, according to professionals. Second, this study aims to give an insight in the experienced value of ACP. Third, the experienced barriers to have ACP conversations are explored. Twenty-four interviews were taken and analyzed with Content Analysis based on Grounded Theory. Three independent external auditors surveilled the analysis. ACP in hospital exists by the grace of the initiative of the actors involved in the case. Professionals perceive fields of tension between one another; barriers to ACP communication. ACP is mainly considered valuable because it is a process that creates time for exploration and reflection.
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8
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O'Reilly M, O'Tuathaigh CMP, Doran K. Doctors' attitudes towards the introduction and clinical operation of do not resuscitate orders (DNRs) in Ireland. Ir J Med Sci 2017; 187:25-30. [PMID: 28508956 DOI: 10.1007/s11845-017-1628-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/27/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do not resuscitate orders (DNRs) are documents which state that should a patient suffer from cardiopulmonary failure, resuscitation should not be attempted. Internationally, DNRs are often misunderstood and used inappropriately in a clinical setting. AIMS The aim of this paper was to determine the current understanding of DNRs and their clinical operation among hospital doctors in Ireland. METHODS A cross-sectional, questionnaire-based study was conducted involving doctors from the Cork teaching hospitals. The questionnaire sought information regarding understanding of DNRs and their clinical operation, as well as attitudes regarding the current absence of relevant Irish guidelines. The questionnaire also collected information regarding demographics, clinical specialty, and level of experience. RESULTS 45.9% (47/103) of all doctors stated that their clinical knowledge was sufficient to draft a DNR, but 48.7% of this group (n = 23) chose the incorrect definition for a DNR when provided with three separate options. Thirty-five percent (n = 36) of all doctors surveyed demonstrated an incorrect understanding of a DNR. Neither specialty nor experience level had any effect on level of understanding of DNRs (p > 0.05). 93.2% (n = 96) agreed that there is a need for introduction of domestic guidelines regarding DNRs. 57.6% (n = 59) would draft more DNRs in the event that such domestic guidelines were in place. CONCLUSIONS A substantial proportion of hospital doctors surveyed demonstrated an incomplete understanding of DNRs and their clinical operation. However, the overwhelming majority of the present sample believe that domestic guidelines are needed on the matter.
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Affiliation(s)
- M O'Reilly
- School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland
| | - C M P O'Tuathaigh
- School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland.
| | - K Doran
- School of Medicine, Brookfield Health Sciences Complex, University College Cork, College Road, Cork, Ireland
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9
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Waldron N, Johnson CE, Saul P, Waldron H, Chong JC, Hill AM, Hayes B. Development of a video-based education and process change intervention to improve advance cardiopulmonary resuscitation decision-making. BMC Health Serv Res 2016; 16:555. [PMID: 27716183 PMCID: PMC5053041 DOI: 10.1186/s12913-016-1803-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 09/28/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Advance cardiopulmonary resuscitation (CPR) decision-making and escalation of care discussions are variable in routine clinical practice. We aimed to explore physician barriers to advance CPR decision-making in an inpatient hospital setting and develop a pragmatic intervention to support clinicians to undertake and document routine advance care planning discussions. METHODS Two focus groups, which involved eight consultants and ten junior doctors, were conducted following a review of the current literature. A subsequent iterative consensus process developed two intervention elements: (i) an updated 'Goals of Patient Care' (GOPC) form and process; (ii) an education video and resources for teaching advance CPR decision-making and communication. A multidisciplinary group of health professionals and policy-makers with experience in systems development, education and research provided critical feedback. RESULTS Three key themes emerged from the focus groups and the literature, which identified a structure for the intervention: (i) knowing what to say; (ii) knowing how to say it; (iii) wanting to say it. The themes informed the development of a video to provide education about advance CPR decision-making framework, improving communication and contextualising relevant clinical issues. Critical feedback assisted in refining the video and further guided development and evolution of a medical GOPC approach to discussing and recording medical treatment and advance care plans. CONCLUSION Through an iterative process of consultation and review, video-based education and an expanded GOPC form and approach were developed to address physician and systemic barriers to advance CPR decision-making and documentation. Implementation and evaluation across hospital settings is required to examine utility and determine effect on quality of care.
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Affiliation(s)
- Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, 3056 Albany Highway, Armadale, 6112, Western Australia, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, 189 Royal Street, East Perth, 6004, Western Australia, Australia.,School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle, 6959, Western Australia, Australia
| | - Claire E Johnson
- Cancer and Palliative Care Research and Evaluation Unit, School of Surgery, The University of Western Australia, 35 Stirling Hwy, Nedlands, 6009, Western Australia, Australia.
| | - Peter Saul
- John Hunter Hospital, Lookout Rd, New Lambton Heights, Newcastle, NSW, 2305, Australia.,Intensive Care, Newcastle Private Hospital, 14 Lookout Rd, New Lambton Heights, Newcastle, NSW, 2305, Australia
| | - Heidi Waldron
- Clinical Teaching - Public Hospitals and Curriculum Development Communication and Clinical Practice Domain, School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle, 6959, Western Australia, Australia
| | - Jeffrey C Chong
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, 3056 Albany Highway, Armadale, 6112, Western Australia, Australia
| | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Kent St, Bentley, 6102, Western Australia, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, 85 Cooper St., Epping, VIC, 3076, Australia.,Medical School, University of Melbourne, Parkville, VIC, 3010, Australia
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Cripe LD, Perkins SM, Cottingham A, Tong Y, Kozak MA, Mehta R. Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress. Am J Hosp Palliat Care 2016; 34:697-703. [PMID: 27432319 DOI: 10.1177/1049909116660516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians' in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients' EOL care preferences. METHODS One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. RESULTS Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. CONCLUSIONS Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents' supportiveness. The interaction between optimism and IRM suggests residents' beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.
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Affiliation(s)
- Larry D Cripe
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Susan M Perkins
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Ann Cottingham
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Yan Tong
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Mary Ann Kozak
- 3 Purdue University School of Pharmacy, West Lafayette, IN, USA
| | - Rakesh Mehta
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
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Perkins GD, Griffiths F, Slowther AM, George R, Fritz Z, Satherley P, Williams B, Waugh N, Cooke MW, Chambers S, Mockford C, Freeman K, Grove A, Field R, Owen S, Clarke B, Court R, Hawkes C. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robert George
- Cicely Saunders Institute, King’s College London, London, UK
- Palliative Care, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Zoe Fritz
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barry Williams
- Patient and Relative Committee, The Intensive Care Foundation, London, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sue Chambers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Mockford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Field
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sarah Owen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Clarke
- Medical School, University of Glasgow, Glasgow, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Binder AF, Huang GC, Buss MK. Uninformed consent: Do medicine residents lack the proper framework for code status discussions? J Hosp Med 2016; 11:111-6. [PMID: 26471452 DOI: 10.1002/jhm.2497] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/16/2015] [Accepted: 09/20/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Conversations eliciting patient preferences about cardiopulmonary resuscitation (CPR) are among the most common examples of informed consent. However, this is rarely recognized and therefore may not include all key elements of informed consent, namely, details and benefits of the procedure, significant risks involved, likelihood of the outcome, and alternative therapeutic options. OBJECTIVE Assess the content of code status discussions as reported by residents to examine whether residents meet requirements of informed consent. DESIGN Prospective, observational, single-center survey study. SETTING Internal medicine residents at an academic medical center. INTERVENTION Medicine residents were surveyed and data were anonymously collected. MEASUREMENTS Content of code status discussions and knowledge of CPR outcomes. RESULTS Among 100 respondents, 66% have code status discussions with most patients upon hospital admission. Two main barriers to discussing code status were lack of time (49%) and lack of rapport (29%). Only 8% reported discussing all 5 elements of informed consent. Less than 10% of the residents correctly answered questions testing knowledge regarding outcomes after cardiac arrest. In logistical regression analyses, residents who included all key elements of informed consent reported more confidence that they provided the information needed for patients to make an informed decision (odds ratio 1.7 [95% confidence interval: 1.2-2.3]). CONCLUSIONS Resident conversations regarding CPR are insufficient in the 5 key elements of informed consent. Framing code status discussions as examples of informed consent may be an effective strategy for educating residents or may improve the quality of these discussions, potentially leading to better patient decisions.
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Affiliation(s)
- Adam F Binder
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Grace C Huang
- Hospitalist Program, Beth Isreal Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mary K Buss
- Ambulatory Palliative Care Services, Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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13
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Rhodes RL, Tindall K, Xuan L, Paulk ME, Halm EA. Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents. Am J Hosp Palliat Care 2015; 32:262-8. [PMID: 24418692 PMCID: PMC4385504 DOI: 10.1177/1049909113517163] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions. OBJECTIVE The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time. METHODS In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006. RESULTS Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient's best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often. CONCLUSIONS Modest improvements were made over time in trainees' exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists.
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Affiliation(s)
- Ramona L Rhodes
- Division of Geriatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate Tindall
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lei Xuan
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - M Elizabeth Paulk
- Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ethan A Halm
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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14
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Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B, Field R, Perkins GD. Do not attempt cardiopulmonary resuscitation (DNACPR) orders: A systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation 2015; 88:99-113. [DOI: 10.1016/j.resuscitation.2014.11.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 12/21/2022]
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15
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Dieltjens SM, Heynderickx PC, Dees MK, Vissers KC. Linguistic Analysis of Face-to-Face Interviews with Patients with An Explicit Request for Euthanasia, their Closest Relatives, and their Attending Physicians: the Use of Modal Verbs in Dutch. Pain Pract 2013; 14:324-31. [DOI: 10.1111/papr.12076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 03/24/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Marianne K. Dees
- Section of Ethics, Philosophy and History of Medicine, Scientific Institute for Quality of Healthcare; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Kris C. Vissers
- Department of Anesthesiology; Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
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16
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Tung EE, Wieland ML, Verdoorn BP, Mauck KF, Post JA, Thomas MR, Bundrick JB, Jaeger TM, Cha SS, Thomas KG. Improved Resident Physician Confidence With Advance Care Planning After an Ambulatory Clinic Intervention. Am J Hosp Palliat Care 2013; 31:275-80. [DOI: 10.1177/1049909113485636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.
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Affiliation(s)
- Ericka E. Tung
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark L. Wieland
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon P. Verdoorn
- Internal Medicine Residency Program, Mayo Graduate School of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
- Hematology and Oncology Fellowship Program, University of Colorado Health Sciences Center, Denver, CO, USA
| | - Karen F. Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason A. Post
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew R. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John B. Bundrick
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas M. Jaeger
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen S. Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kris G. Thomas
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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17
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Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med 2011; 26:791-7. [PMID: 21286839 PMCID: PMC3138592 DOI: 10.1007/s11606-011-1632-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/16/2010] [Accepted: 12/27/2010] [Indexed: 12/11/2022]
Abstract
Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.
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18
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Jacobsen J, Robinson E, Jackson VA, Meigs JB, Billings JA. Development of a cognitive model for advance care planning discussions: results from a quality improvement initiative. J Palliat Med 2011; 14:331-6. [PMID: 21247300 DOI: 10.1089/jpm.2010.0383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Residents struggle with advance care planning (ACP) discussions in the inpatient setting, and may not be aware of newer models for ACP that stress the importance of giving prognostic information and making a recommendation about cardiopulmonary resuscitation to patients and families. METHODS A controlled study of a cognitive model for ACP embedded in a quality improvement (QI) project. RESULTS In the setting of a QI project for medical residents and interdisciplinary staff, we developed and implemented a cognitive model of ACP discussions that involved two types of meetings for patients: (1) information-sharing meetings for seriously ill but clinically stable patients and (2) decision-making meetings for clinically unstable patients. Patients on the intervention floor were significantly more likely to have a discussion about goals of care (33.8%) than patients on the control floor (21.2%, p = < 0.001) and significantly more likely to have a limitation of life-sustaining treatment upon discharge (19.1% vs. 13.9%, p = 0.04). CONCLUSIONS For both residents and interdisciplinary staff, application of a cognitive model that clearly defines goals and expectations for ACP discussions prior to meeting with patients and families improves rates of ACP discussions.
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Affiliation(s)
- Juliet Jacobsen
- Palliative Care Service, Massachusetts General Hospital , Boston, MA 02114, USA.
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19
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Siddiqui MF, Holley JL. Residents’ Practices and Perceptions About Do Not Resuscitate Orders and Pronouncing Death: An Opportunity for Clinical Training. Am J Hosp Palliat Care 2010; 28:94-7. [DOI: 10.1177/1049909110374599] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Although ‘‘Do not resuscitate’’ (DNR) orders are among the most commonly discussed patient preference treatment measures, few studies have assessed internal medicine residents’ views on this complex topic. Our objective was to assess resident practices in establishing code status. We also examined resident training and experiences in pronouncing death. Methods: An 18-question survey addressing DNR discussions and pronouncing death was emailed to internal medicine residents in the state of Illinois. Each question had multiple-choice options. Results: A total of 175 residents completed the questionnaire (22% response rate). Seventy-eight percent of the residents had discussed DNR status with patients or their families at least 9 times. However, only one third of the residents felt very comfortable in such discussions. Only 26% of the residents had been observed by a faculty member during a code status discussion and fewer (16%) while pronouncing death. Do not resuscitate discussions rarely occurred in an outpatient clinic (27%). Most residents (90%) thought they would benefit from formal training in DNR discussion. Conclusion: Although most residents discuss DNR status with patients and families, only a quarter are observed in such discussions by attending physicians and only a third feel comfortable with this aspect of clinical care. Developing a structured residency program curriculum to address resident skills in end-of-life care would benefit residency training.
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Affiliation(s)
| | - Jean L. Holley
- University of Illinois, Urbana-Champaign, IL, USA, Carle Foundation Hospital, Urbana, IL, USA
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20
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Age as a Deciding Factor in the Consideration of Futility for a Medical Intervention in Patients Among Internal Medicine Physicians in Two Practice Locations. J Am Med Dir Assoc 2010; 11:421-7. [DOI: 10.1016/j.jamda.2010.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/25/2010] [Accepted: 01/25/2010] [Indexed: 11/19/2022]
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21
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Colbert CY, Mirkes C, Ogden PE, Herring ME, Cable C, Myers JD, Ownby AR, Boisaubin E, Murguia I, Farnie MA, Sadoski M. Enhancing competency in professionalism: targeting resident advance directive education. J Grad Med Educ 2010; 2:278-82. [PMID: 21975633 PMCID: PMC2941387 DOI: 10.4300/jgme-d-10-00003.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 02/12/2010] [Accepted: 04/22/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Education about advance directives typically is incorporated into medical school curricula and is not commonly offered in residency. Residents' experiences with advance directives are generally random, nonstandardized, and difficult to assess. In 2008, an advance directive curriculum was developed by the Scott & White/Texas A&M University System Health Science Center College of Medicine (S&W/Texas A&M) internal medicine residency program and the hospital's legal department. A pilot study examining residents' attitudes and experiences regarding advance directives was carried out at 2 medical schools. METHODS In 2009, 59 internal medicine and family medicine residents (postgraduate year 2-3 [PGY-2, 3]) completed questionnaires at S&W/Texas A&M (n = 32) and The University of Texas Medical School at Houston (n = 27) during a validation study of knowledge about advance directives. The questionnaire contained Likert-response items assessing attitudes and practices surrounding advance directives. Our analysis included descriptive statistics and analysis of variance (ANOVA) to compare responses across categories. RESULTS While 53% of residents agreed/strongly agreed they had "sufficient knowledge of advance directives, given my years of training," 47% disagreed/strongly disagreed with that statement. Most (93%) agreed/strongly agreed that "didactic sessions on advance directives should be offered by my hospital, residency program, or medical school." A test of responses across residency years with ANOVA showed a significant difference between ratings by PGY-2 and PGY-3 residents on 3 items: "Advance directives should only be discussed with patients over 60," "I have sufficient knowledge of advance directives, given my years of training," and "I believe my experience with advance directives is adequate for the situations I routinely encounter." CONCLUSION Our study highlighted the continuing need for advance directive resident curricula. Medical school curricula alone do not appear to be sufficient for residents' needs in this area.
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Affiliation(s)
- Colleen Y. Colbert
- Corresponding author: Colleen Y. Colbert, PhD, Scott & White Healthcare, 2401 South 31st Street, Temple, TX 76508, 254.724.8882,
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22
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Almoosa KF, Goldenhar LM, Panos RJ. Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients. J Crit Care 2009; 24:280-7. [PMID: 19427765 DOI: 10.1016/j.jcrc.2009.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 01/30/2009] [Accepted: 03/08/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions. MATERIALS AND METHODS Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes. RESULTS Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5). CONCLUSIONS Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.
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Affiliation(s)
- Khalid F Almoosa
- University of Cincinnati University Hospital, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH, USA.
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Forbes T, Goeman E, Stark Z, Hynson J, Forrester M. Discussing withdrawing and withholding of life-sustaining medical treatment in a tertiary paediatric hospital: a survey of clinician attitudes and practices. J Paediatr Child Health 2008; 44:392-8. [PMID: 18638330 DOI: 10.1111/j.1440-1754.2008.01351.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To better understand current attitudes and practices relating to discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT) among medical staff in the paediatric setting. METHODS An anonymous online survey of paediatricians (senior medical staff - SMS) and paediatric trainees (junior medical staff - JMS) likely to be involved in the care of children with life limiting illness. RESULTS A total of 162 responses were obtained (response rate 42%). SMS indicated feeling more comfortable with their abilities to discuss WWLSMT than JMS. Barriers to discussing WWLSMT were numerous and included clinician concerns about family readiness for the discussion, prognostic uncertainty, family disagreement with the treating team regarding the child's prognosis/diagnosis and concerns about how to manage family requests for treatments that are not perceived to be in the child's best interests. Fifty-eight per cent of JMS and 35.8% of SMS reported receiving no specific communication training regarding WWLSMT. Most learned through experience and by observing more senior colleagues. There was a high level of support for additional training in this area and for the provision of resources such as discussion guidelines and a structured form for documenting the outcomes WWLSMT discussions. CONCLUSION The majority of JMS feel less comfortable with their abilities to facilitate these discussions than their senior colleagues. The results of this study suggest that although confidence correlates with experience, junior and senior clinicians are eager to improve their skills through ongoing professional development and the provision of resources. The education needs of JMS and SMS appear to be different.
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Affiliation(s)
- Tom Forbes
- Royal Children's Hospital, Melbourne, Victoria, Australia
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24
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Sears SR, Woodward JT, Twillman RK. What Do I Have To Lose? Effects of a Psycho-Educational Intervention on Cancer Patient Preference for Resuscitation. J Behav Med 2007; 30:533-44. [PMID: 17712617 DOI: 10.1007/s10865-007-9128-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 08/01/2007] [Indexed: 11/25/2022]
Abstract
This original empirical study examined effects of a psycho-educational intervention on cancer patients' knowledge, concern, and preferences for cardiopulmonary resuscitation (CPR). We examined message framing as one factor that might impact subsequent decision making. In addition, we examined personality and coping style as predictors and moderators of patients' reactions to an informational intervention. As hypothesized, participants initially underestimated CPR complications and overestimated survival rates. The intervention significantly increased concern, improved knowledge, and decreased preference for CPR, particularly for participants receiving both numerical and descriptive information. Message framing of survival data did not uniquely affect CPR preference. Higher optimism predicted less increase in concern about CPR, and higher hope predicted greater decrease in preference for CPR. More approach coping related to increased concern about CPR and decreased preference for CPR.
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Affiliation(s)
- Sharon R Sears
- Department of Psychology, Fort Lewis College, 1000 Rim Drive, Durango, CO 81301, USA.
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