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van der Werff HFL, Michelet TH, Fredheim OM, Steine S. "Do not resuscitate" order and end-of-life treatment in a cohort of deceased in a Norwegian University Hospital. Acta Anaesthesiol Scand 2022; 66:1009-1015. [PMID: 35699950 PMCID: PMC9544634 DOI: 10.1111/aas.14104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022]
Abstract
Background A “Do not resuscitate” (DNR) order implies that cardiopulmonary resuscitation will not be started. Absent or delayed DNR orders in advanced chronic disease may indicate suboptimal communication about disease stage, prognosis, and treatment goals. The study objective was to determine clinical practice and patient involvement regarding DNR and the prevalence of life‐prolonging treatment in the last week of life. Methods A cross‐sectional observational study was made of a cohort of 315 deceased from a large general hospital in Norway. Data on DNR and other treatment limitations, life‐prolonging treatment in the last week of life, and cause of death were obtained from medical records. Results A DNR order was documented for 287 (91%) patients. Almost half the DNR orders, 142 (49%), were made during the last 7 days of life. The main causes of death were cancer (31%), infectious diseases (31%), and cardiovascular diseases (19%). The most frequent life‐prolonging treatments during the last week of life were intravenous fluids in 221 patients (70%) and antibiotics in 198 (63%). During the last week of life, 103 (36%) patients received ICU treatment. Death by cancer (odds ratio 2.5, 95% confidence interval 1.24–5.65) and DNR decision made by a palliative care physician (odds ratio 3.4, 95% CI 1.21–3.88) were predictors of not receiving life‐prolonging treatment. Conclusion The findings of a high prevalence of life‐prolonging treatment in the last week of life and DNR orders being made close to the time of death indicate that decisions about limiting life‐prolonging treatment are often postponed until the patient's death is imminent.
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Affiliation(s)
| | - Torstein H Michelet
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Olav M Fredheim
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Complex Symptom Disorders, St. Olavs Hospital, Trondheim, Norway
| | - Siri Steine
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
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AbuYahya O, Abuhammad S, Hamoudi B, Reuben R, Yaqub M. The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia. Int J Clin Pract 2021; 75:e14331. [PMID: 33960067 DOI: 10.1111/ijcp.14331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR). METHOD A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study. RESULTS Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05). CONCLUSION It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders. IMPLICATION TO CLINICAL PRACTICE It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.
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Affiliation(s)
- Omar AbuYahya
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Sawsan Abuhammad
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Bara Hamoudi
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Ranjni Reuben
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Muawiyah Yaqub
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
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Sutton L, Goodacre S, Thomas B, Connelly S. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study. Resuscitation 2021; 164:130-138. [PMID: 33961960 PMCID: PMC8095017 DOI: 10.1016/j.resuscitation.2021.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/14/2021] [Accepted: 04/27/2021] [Indexed: 11/15/2022]
Abstract
AIMS We aimed to describe the characteristics and outcomes of adults admitted to hospital with suspected COVID-19 according to their DNACPR decisions, and identify factors associated with DNACPR decisions. METHODS We undertook a secondary analysis of 13,977 adults admitted to hospital with suspected COVID-19 and included in the Pandemic Respiratory Infection Emergency System Triage (PRIEST) study. We recorded presenting characteristics and outcomes (death or organ support) up to 30 days. We categorised patients as early DNACPR (before or on the day of admission) or late/no DNACPR (no DNACPR or occurring after the day of admission). We undertook descriptive analysis comparing these groups and multivariable analysis to identify independent predictors of early DNACPR. RESULTS We excluded 1249 with missing DNACPR data, and identified 3929/12748 (31%) with an early DNACPR decision. They had higher mortality (40.7% v 13.1%) and lower use of any organ support (11.6% v 15.7%), but received a range of organ support interventions, with some being used at rates comparable to those with late or no DNACPR (e.g. non-invasive ventilation 4.4% v 3.5%). On multivariable analysis, older age (p < 0.001), active malignancy (p < 0.001), chronic lung disease (p < 0.001), limited performance status (p < 0.001), and abnormal physiological variables were associated with increased recording of early DNACPR. Asian ethnicity was associated with reduced recording of early DNACPR (p = 0.001). CONCLUSIONS Early DNACPR decisions were associated with recognised predictors of adverse outcome, and were inversely associated with Asian ethnicity. Most people with an early DNACPR decision survived to 30 days and many received potentially life-saving interventions. REGISTRATION ISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533.
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Affiliation(s)
- Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | - Sarah Connelly
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
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Mehlis K, Bierwirth E, Laryionava K, Mumm F, Heussner P, Winkler EC. Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital. ESMO Open 2020; 5:e000950. [PMID: 33109628 PMCID: PMC7592262 DOI: 10.1136/esmoopen-2020-000950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background Decisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT. Methods This prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form. Results Overall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia. Conclusion Our results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.
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Affiliation(s)
- Katja Mehlis
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany.
| | - Elena Bierwirth
- Institut für physikalische und rehabilitative Medizin, Klinikum Ingolstadt GmbH, Ingolstadt, Germany
| | - Katsiaryna Laryionava
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Friederike Mumm
- Department of Medicine III, University Hospital Munich, Munich, Germany
| | - Pia Heussner
- Zentrum Innere Medizin, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany
| | - Eva C Winkler
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
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Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review. Palliat Support Care 2020; 19:348-354. [PMID: 32854813 DOI: 10.1017/s1478951520000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients. OBJECTIVE A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients. METHOD We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI). RESULTS A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result. SIGNIFICANCE OF RESULTS Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.
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Willemse S, Smeets W, van Leeuwen E, Nielen-Rosier T, Janssen L, Foudraine N. Spiritual care in the intensive care unit: An integrative literature research. J Crit Care 2020; 57:55-78. [PMID: 32062288 DOI: 10.1016/j.jcrc.2020.01.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/26/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study is to review the literature for three major domains in relation to spiritual care in the ICU, namely Quality of Life (QoL), Quality of Care (QoC), and Education (E). METHOD An integrative literature research. RESULTS The 113 selected articles reveal that spirituality is an essential component of QoL and that complementary and effective spiritual care (SC) relieves distress of patients and their relatives. Furthermore, the contribution of SC to quality of care is: 1) diagnosing and addressing spiritual and emotional needs among patients and their relatives; 2) offering spiritual comfort to the patient in distress; 3) increased spiritual well-being of both patients and their relatives; 4) increased family satisfaction in general and by shared decision-making. Finally, the literature reveals the necessity to improve SC knowledge and skills of ICU healthcare professionals (IC HCPs) through relevant training courses. CONCLUSION SC contributes to QoL and QoC. The literature indicates that IC HCPs acknowledge the need to improve their SC knowledge and skills to enhance complementary, effective SC. Further research on SC as an integrated part of daily ICU care is necessary to improve QoL and QoC of patients and their relatives.
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Affiliation(s)
- Suzan Willemse
- Department of Spiritual Care, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, the Netherlands.
| | - Wim Smeets
- Department of Spiritual and Pastoral Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, the Netherlands.
| | - Evert van Leeuwen
- Department of Ethics, Philosophy and History of Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, the Netherlands.
| | - Trijnie Nielen-Rosier
- Department of Spiritual and Pastoral Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, the Netherlands.
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, P.O. Box 7777, 5500 MB Veldhoven, the Netherlands.
| | - Norbert Foudraine
- Department of Critical Care, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, the Netherlands.
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Choi JY, Kim SW, Yoon SJ, Kang MG, Kim KI, Kim CH. Impact of frailty on do-not-resuscitate orders and healthcare transitions among elderly Koreans with pneumonia. Clin Interv Aging 2018; 13:2237-2245. [PMID: 30464432 PMCID: PMC6219099 DOI: 10.2147/cia.s181400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Pneumonia poses a significant health risk in aging societies. We aimed to elucidate the determinative value of frailty for do-not-resuscitate (DNR) orders in pneumonia patients. Patients and methods This was a retrospective cohort study conducted at the Seoul National University Bundang Hospital (SNUBH) in Korea. Medical records of 431 pneumonia patients, aged 65 years and older, who were admitted between June 2014 and May 2015 were analyzed. Patients were categorized into DNR and no-DNR groups. Results Among the 65 patients (15.1% of pneumonia patients) who completed DNR documents, 24 patients were survived, and 21 patients decided imminent to death (<24 hours before death), with all decisions determined by surrogates. The DNR group tended to be older and frail, with higher rates of renal impairment and malnutrition, and had a lower microbiology detection effort than the no-DNR group. The DNR group used a high number of broad-spectrum antibiotics, experienced high levels of in-hospital (63.1% vs 5.7%, P<0.001) and 30-day (64.6% vs 9.6%, P<0.001) mortality rates, and had prolonged hospital stays (median length of hospital stay, 12 vs 9 days, P=0.020). Frailty was independently associated with DNR status even after adjustment for sepsis, septic shock, and the pneumonia severity index (PSI) score. Frailty also significantly influenced healthcare setting transitions after adjustment for sepsis, septic shock, and the PSI. Conclusion We identified the factors associated with DNR orders and their prognoses among elderly Koreans with pneumonia. Frailty was significantly associated with DNR decision and healthcare setting transitions in pneumonia patients.
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Affiliation(s)
- Jung-Yeon Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea,
| | - Sun-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea,
| | - Sol-Ji Yoon
- Department of Internal Medicine, Kangwon National University Hospital Gangwon-Do 200-722, Republic of Korea
| | - Min-Gu Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea,
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea,
| | - Cheol-Ho Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea,
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Hill J, Gerace A, Oster C, Ullah S. Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study. AUST HEALTH REV 2018; 43:432-440. [PMID: 30103850 DOI: 10.1071/ah18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/04/2018] [Indexed: 11/23/2022]
Abstract
Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a 'do not attempt resuscitation' order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.
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Affiliation(s)
- Jo Hill
- Older Persons Mental Health Services, Repatriation General Hospital, 216 Daws Road, Daw Park, SA 5041, Australia
| | - Adam Gerace
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Candice Oster
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
| | - Shahid Ullah
- College of Nursing and Health Sciences, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001, Australia.
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Reversals and limitations on high-intensity, life-sustaining treatments. PLoS One 2018; 13:e0190569. [PMID: 29489814 PMCID: PMC5830043 DOI: 10.1371/journal.pone.0190569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
Importance Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs. Methods This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders. Results 10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28–1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69–2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49–2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27–2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38–1.48] per decade), female (HR 1.30 [95% CI 1.17–1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25–1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48–2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42–1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33–1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15–1.72]). Conclusion Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.
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Williams BR, Amos Bailey F, Kvale E, Steil N, Goode PS, Kennedy RE, Burgio KL. Continuation of non-essential medications in actively dying hospitalised patients. BMJ Support Palliat Care 2017; 7:450-457. [PMID: 28904011 DOI: 10.1136/bmjspcare-2016-001229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 05/30/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients. METHODS This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation's Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans. RESULTS Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002). CONCLUSIONS Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients' actively dying status.
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Affiliation(s)
- Beverly Rosa Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - F Amos Bailey
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, Denver Health Medical Center, University of Colorado, Denver, Colorado, USA
| | - Elizabeth Kvale
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Neal Steil
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Palliative Care Section, Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Patricia S Goode
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathryn L Burgio
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Dasch B, Kalies H, Feddersen B, Ruderer C, Hiddemann W, Bausewein C. Care of cancer patients at the end of life in a German university hospital: A retrospective observational study from 2014. PLoS One 2017; 12:e0175124. [PMID: 28384214 PMCID: PMC5383201 DOI: 10.1371/journal.pone.0175124] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023] Open
Abstract
Background Cancer care including aggressive treatment procedures during the last phase of life in patients with incurable cancer has increasingly come under scrutiny, while integrating specialist palliative care at an early stage is regarded as indication for high quality end-of-life patient care. Aim To describe the demographic and clinical characteristics and the medical care provided at the end of life of cancer patients who died in a German university hospital. Methods Retrospective cross-sectional study on the basis of anonymized hospital data for cancer patients who died in the Munich University Hospital in 2014. Descriptive analysis and multivariate logistic regression analyses for factors influencing the administration of aggressive treatment procedures at the end of life. Results Overall, 532 cancer patients died. Mean age was 66.8 years, 58.5% were men. 110/532 (20.7%) decedents had hematologic malignancies and 422/532 (79.3%) a solid tumor. Patients underwent the following medical interventions in the last 7/30 days: chemotherapy (7.7%/38.3%), radiotherapy (2.6%/6.4%), resuscitation (8.5%/10.5%), surgery (15.2%/31.0%), renal replacement therapy (12.0%/16.9%), blood transfusions (21.2%/39.5%), CT scan (33.8%/60.9%). In comparison to patients with solid tumors, patients with hematologic malignancies were more likely to die in intensive care (25.4% vs. 49.1%; p = 0.001), and were also more likely to receive blood transfusions (OR 2.21; 95% CI, 1.36 to 3.58; p = 0.001) and renal replacement therapy (OR 2.65; 95% CI, 1.49 to 4.70; p = 0.001) in the last 7 days of life. Contact with the hospital palliative care team had been initiated in 161/532 patients (30.3%). In 87/161 cases (54.0%), the contact was initiated within the last week of the patient’s life. Conclusions Overambitious treatments are still reality at the end of life in cancer patients in hospital but patients with solid tumors and hematologic malignancies have to be differentiated. More efforts are necessary for the timely inclusion of specialist palliative care.
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Affiliation(s)
- Burkhard Dasch
- Department of Palliative Medicine, Munich University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
- * E-mail:
| | - Helen Kalies
- Department of Palliative Medicine, Munich University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Berend Feddersen
- Department of Palliative Medicine, Munich University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Caecilie Ruderer
- Specialized Palliative Home Care, Districts of Berchtesgaden and Traunstein, Germany
| | - Wolfgang Hiddemann
- Department of Internal Medicine III, Munich University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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12
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Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA. Provider and Patient Gender Influence on Timing of Do-Not-Resuscitate Orders in Hospitalized Patients with Cancer. J Palliat Med 2016; 19:728-33. [PMID: 27159269 DOI: 10.1089/jpm.2015.0388] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND End-of-life decisions and advance directives require timely physician-patient discussions but barriers exist to these discussions. OBJECTIVE To evaluate the influence of physician and patient gender on the timing of inpatient do-not-resuscitate (DNR) orders. DESIGN Retrospective cohort study. SETTING/SUBJECTS All adult patients (≥18 years) with cancer who received inpatient DNR orders at The University of Texas MD Anderson Cancer Center between January 2011 and December 2013. MEASUREMENTS Gender interaction between physicians and patients towards timing of the DNR order. RESULTS We identified 4,157 unique patients with a cancer diagnosis. These patients were treated by 353 physicians, of whom 123 (34.8%) were females and 230 (65.2%) were males. Multivariate analysis showed female patients were 1.3 times more likely to have early DNR orders written during hospital admission than were male patients (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.07-1.50). When comparing gender interaction between physicians and patients, our results showed that female physicians were 1.5 times more likely to write early DNR orders with their female patients than for their male patients (OR, 1.48; 95% CI, 1.13-1.94). Same gender physician-patient dyads were not found between male physician and their patients (OR, 1.09; 95% CI, 0.91-1.31). Higher age, more comorbid conditions, and progression of diseases were also associated with early DNR orders (all p < 0.01). CONCLUSION Female patients are more likely to receive early DNR orders from their female physicians. Gender and gender interaction between physician and patients may potentially influence the timing of receiving DNR order.
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Affiliation(s)
| | - Lee Cheng
- 2 Department of Clinical Effectiveness, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Alma Y DeJesus
- 2 Department of Clinical Effectiveness, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Elizabeth L Travis
- 3 Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Maria A Rodriguez
- 4 Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center , Houston, Texas
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13
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Kim YS, Escobar GJ, Halpern SD, Greene JD, Kipnis P, Liu V. The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults. J Am Geriatr Soc 2016; 64:981-9. [PMID: 27119583 DOI: 10.1111/jgs.14048] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Northern California (KPNC). PARTICIPANTS Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525). MEASUREMENTS Participants were divided according to age (<65, 65-84, ≥85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations. RESULTS At admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR) = 2.27, 95% confidence interval (CI) = 2.16-2.39; aged ≥85, OR = 6.43, 95% CI = 6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR = 0.73, 95% CI = 0.65-0.83; aged ≥85, OR = 0.46, 95% CI = 0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P < .001). CONCLUSION Changes in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.
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Affiliation(s)
- Yan S Kim
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Gabriel J Escobar
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Fostering Improvement in End-of-Life Decision Science Program, Leonard David Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John D Greene
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
| | - Patricia Kipnis
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California.,Decision Support, Kaiser Foundation Health Plan, Oakland, California
| | - Vincent Liu
- Division of Research and Systems Research Initiative, Kaiser Permanente Northern California, Oakland, California
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14
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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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15
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Crowther MR, Huang CHS, Allen RS. Rewards and unique challenges faced by African-American custodial grandmothers: the importance of future planning. Aging Ment Health 2016; 19:844-52. [PMID: 25345592 DOI: 10.1080/13607863.2014.967175] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This exploratory study examined the context and consequences of custodial grandparenting, along with attitudes and preferences regarding future planning among 22 African-American custodial grandmothers. METHOD A mixed-method research design was employed. Based on our integration of two theories regarding future planning and health behavior change, caregiving, emotional distress, religiosity and spirituality, and future planning were assessed using questionnaires along with semi-structured interviews. RESULTS African-American custodial grandmothers (mean age M = 53.64, SD = 9.58) perceived their caregiving role as rewarding (72%) yet challenging (86%). More than 40% reported significant emotional distress (CES-D ≥ 16) that warrants clinical attention. Findings showed that while 64% of study participants had future plans regarding who will substitute in their caregiving role if they become incapacitated, only 9% had completed a living will. Three major themes emerged regarding custodial grandmothers' caregiving role which includes: (1) rewards; (2) challenges including feeling overwhelmed and health concerns; and (3) caregiving decisions including conflicts between 'My plan was…/put self on-hold' for grandchildren and difficulty with future planning. These themes highlighted the dynamics of caregiving across time, including current context and the ongoing process of decision-making. CONCLUSION Findings suggest that while African-American custodial grandmothers find caregiving rewarding, they face unique challenges in contemplating and developing future plans. Custodial grandmothers think about substitute caregivers for their grandchildren but need assistance communicating a plan focused on their own needs for future care. Culturally sensitive interventions designed to facilitate effective utilization of future plans within this caregiver population are needed.
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Affiliation(s)
- Martha R Crowther
- a Department of Psychology , The University of Alabama , Tuscaloosa , AL , USA
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16
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Lin KH, Chen YS, Chou NK, Huang SJ, Wu CC, Chen YY. The Associations Between the Religious Background, Social Supports, and Do-Not-Resuscitate Orders in Taiwan: An Observational Study. Medicine (Baltimore) 2016; 95:e2571. [PMID: 26817913 PMCID: PMC4998287 DOI: 10.1097/md.0000000000002571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Prior studies have demonstrated important implications related to religiosity and a do-not-resuscitate (DNR) decision. However, the association between patients' religious background and DNR decisions is vague. In particular, the association between the religious background of Buddhism/Daoism and DNR decisions has never been examined. The objective of this study was to examine the association between patients' religious background and their DNR decisions, with a particular focus on Buddhism/Daoism.The medical records of the patients who were admitted to the 3 surgical intensive care units (SICU) in a university-affiliated medical center located at Northern Taiwan from June 1, 2011 to December 31, 2013 were retrospectively collected. We compared the clinical/demographic variables of DNR patients with those of non-DNR patients using the Student t test or χ test depending on the scale of the variables. We used multivariate logistic regression analysis to examine the association between the religious backgrounds and DNR decisions.A sample of 1909 patients was collected: 122 patients had a DNR order; and 1787 patients did not have a DNR order. Old age (P = 0.02), unemployment (P = 0.02), admission diagnosis of "nonoperative, cardiac failure/insufficiency" (P = 0.03), and severe acute illness at SICU admission (P < 0.01) were significantly associated with signing of DNR orders. Patients' religious background of Buddhism/Daoism (P = 0.04), married marital status (P = 0.02), and admission diagnosis of "postoperative, major surgery" (P = 0.02) were less likely to have a DNR order written during their SICU stay. Furthermore, patients with poor social support, as indicated by marital and working status, were more likely to consent to a DNR order during SICU stay.This study showed that the religious background of Buddhism/Daoism was significantly associated with a lower likelihood of consenting to a DNR, and poor social support was significantly associated with a higher likelihood of having a DNR order written during SICU stay.
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Affiliation(s)
- Kuan-Han Lin
- From the Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine (K-HL, C-CW, Y-YC); and Department of Surgery, National Taiwan University College of Medicine, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan (Y-SC, N-KC, S-JH)
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17
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El-Jawahri A, Mitchell SL, Paasche-Orlow MK, Temel JS, Jackson VA, Rutledge RR, Parikh M, Davis AD, Gillick MR, Barry MJ, Lopez L, Walker-Corkery ES, Chang Y, Finn K, Coley C, Volandes AE. A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients. J Gen Intern Med 2015; 30:1071-80. [PMID: 25691237 PMCID: PMC4510229 DOI: 10.1007/s11606-015-3200-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/17/2014] [Accepted: 01/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. INTERVENTION Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). MAIN MEASURES The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). CONCLUSIONS Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. TRIAL REGISTRATION Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.
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Affiliation(s)
- Areej El-Jawahri
- Hematology-Oncology Department, Massachusetts General Hospital, 55 Fruit Street, Cox 120, Boston, MA, 02114, USA,
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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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19
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Mancini ME. It's time to understand the dynamics of "do not attempt cardiopulmonary resuscitation" orders. Resuscitation 2014; 88:A1-2. [PMID: 25530358 DOI: 10.1016/j.resuscitation.2014.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 11/26/2022]
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‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology. Resuscitation 2014; 85:1644-5. [DOI: 10.1016/j.resuscitation.2014.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/14/2014] [Indexed: 11/21/2022]
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21
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Teaster PB, O'Brien JG. The Elder Mistreatment of Overtreatment at End of Life. ACTA ACUST UNITED AC 2014. [DOI: 10.1093/ppar/pru025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Alsirafy SA, Mohammed AA, Al-Zahrani AS, Raheem AA, El-Kashif AT. The Relation Between the Timing of Palliative Care and the Frequency and Timing of Do-Not-Resuscitate Orders Among Cancer Deaths in a Tertiary Care Hospital. Am J Hosp Palliat Care 2014; 32:544-8. [PMID: 24671030 DOI: 10.1177/1049909114529014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The medical records of 246 in-hospital cancer deaths were reviewed to explore the relation between palliative care (PC) timing and the frequency and timing of do-not-resuscitate (DNR) designation. The rate of DNR designation was 100% in patients referred to PC and 82% in those never referred (P < .001). Patients were grouped into 4 groups: early PC (>90 days from PC referral to death), intermediate PC (>30-90 days), late PC (≤30 days), and no PC. The median DNR to death time was 96, 41, 11, and 3 days, respectively (P < .001). The proportion of intensive care unit (ICU) deaths was 0%, 1%, 3%, and 27%, respectively (P < .001). In conclusion, in a tertiary care hospital, earlier PC was associated with earlier DNR designation and less frequent ICU deaths among in-hospital cancer deaths.
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Affiliation(s)
- Samy A Alsirafy
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Amrallah A Mohammed
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Medical Oncology Department, Faculty of medicine, Zagazig University, Sharkia, Egypt
| | | | - Ahmad A Raheem
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Medical Oncology Department, Faculty of medicine, Zagazig University, Sharkia, Egypt
| | - Amr T El-Kashif
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia Clinical Oncology Department, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
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Abstract
OBJECTIVE Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved. DESIGN We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included. SETTING Sixteen bed medical ICU at a single large academic hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d). CONCLUSION No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.
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Kao CY, Wang HM, Tang SC, Huang KG, Jaing TH, Liu CY, Liu KH, Shen WC, Wu JH, Hung YS, Hsu HC, Chen JS, Liau CT, Lin YC, Su PJ, Hsieh CH, Chou WC. Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service. J Pain Symptom Manage 2014; 47:271-82. [PMID: 23856097 DOI: 10.1016/j.jpainsymman.2013.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Since the development of palliative care in the 1980s, "do not resuscitate" (DNR) has been promoted worldwide to avoid unnecessary resuscitation in terminally ill cancer patients. OBJECTIVES This study aimed to evaluate the effect of a palliative care consultation service (PCCS) on DNR designation and to identify a subgroup of patients who would potentially benefit from care by the PCCS with respect to DNR designation. METHODS In total, 2995 terminally ill cancer patients (with a predicted life expectancy of less than six months by clinician estimate) who received care by the PCCS between January 2006 and December 2010 at a single medical center in Taiwan were selected. Among these, the characteristics of 2020 (67.4%) patients who were not designated as DNR at the beginning of care by the PCCS were retrospectively analyzed to identify variables pertinent to DNR designation. RESULTS A total of 1301 (64%) of 2020 patients were designated as DNR at the end of care by the PCCS. Male gender and primary liver cancer were characteristics more predominantly found among DNR-designated patients who also had worse performance status, higher prevalence of physical distress, and shorter intervals from palliative care referral to death than did patients without DNR designation. On univariate analysis, a higher probability of DNR designation was associated with male gender, duration of care by the PCCS of more than 14 days, patients' prognostic awareness, family's diagnostic and prognostic awareness, and high Palliative Prognostic Index (PPI) scores. On multivariate analysis, duration of care by the PCCS, patients' prognostic awareness, family's diagnostic and prognostic awareness, and a high PPI score constituted independent variables predicting DNR-designated patients at the end of care by the PCCS. CONCLUSION DNR designation was late in terminally ill cancer patients. DNR-designated cancer patient indicators were high PPI scores, patients' prognostic awareness, family's diagnostic and prognostic awareness, and longer durations of care by the PCCS.
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Affiliation(s)
- Chen-Yi Kao
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Ming Wang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Shu-Chuan Tang
- Department of Nursing, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Kuan-Gen Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Tang-Her Jaing
- Division of Hematology and Oncology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chien-Ying Liu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Keng-Hao Liu
- Department of Surgery, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Shen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Chih Hsu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chi-Ting Liau
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yung-Chang Lin
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Po-Jung Su
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China.
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Kypriotakis G, Francis LE, O'Toole E, Towe TP, Rose JH. Preferences for aggressive care in underserved populations with advanced-stage lung cancer: looking beyond race and resuscitation. Support Care Cancer 2013; 22:1251-9. [PMID: 24317850 DOI: 10.1007/s00520-013-2079-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/25/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE This paper examines the relationship between race, religiousness, spiritual well-being, antitumor treatment and preference for aggressive care among Black and White patients with advanced stage lung cancer receiving ambulatory cancer care in an urban setting. METHODS A cross-sectional exploration of patients enrolled in a Cleveland-based longitudinal study after initial diagnosis of advanced lung cancer were interviewed in Cleveland regarding religiousness, spiritual well-being, preferences for cardiopulmonary resuscitation (CPR), goals of aggressive care, and willingness to tolerate adverse health states. Receipt of antitumor treatment was identified from medical records. RESULTS We analyzed data from 67 Black and 129 White patients (N=196). Regression analysis for CPR showed that race was not associated with preference for CPR (OR=1.12, CI 0.44-2.85). The odds of choosing CPR were three times higher among patients receiving antitumor treatment (OR=3.26, CI 1.12-9.44). Greater willingness to endure adverse health states was associated with higher spiritual well-being scores (b=0.12, CI 0.01-0.25). Choosing goals to extend life versus relieve pain was higher among persons with higher spiritual well-being as well (RRR=1.08, CI 1.01-1.16), yet the relationship with religiousness was negative (RRR=0.46, CI 0.22-0.98). CONCLUSIONS After controlling for multiple factors, race was associated only with CPR, but not with other measures of preference for aggressive care. In addition, receipt of active antitumor treatment was positively associated with preference for CPR and spiritual well-being was important to setting end-of-life care goals and perspectives. Future directions for tailoring end-of-life care decision-making initiatives should move beyond race and discussions of CPR alone and focus on a full spectrum of patient beliefs and preferences at the end of life.
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Affiliation(s)
- George Kypriotakis
- Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, 44106, USA,
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Goh, Senior Associate Editor CR. Medicalization of Dying: Are We Turning the Corner? J Palliat Med 2012; 15:728-9. [DOI: 10.1089/jpm.2012.9579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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