1
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Bigelow S, Medzon R, Siegel M, Jin R. Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions. J Palliat Care 2024; 39:3-12. [PMID: 36594209 DOI: 10.1177/08258597221149402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: This study aims to evaluate the potential impact of addressing goals-of-care (GOC) with selected patients in the emergency department (ED), GOC documentation, hospital utilization, and patient satisfaction. Method: This is a single-center, retrospective, and prospective, observational convenience-sample study. ED registered nurses (ED RNs) received standardized GOC conversation training. Their selection criteria included a selection interview, a minimum of 3 years of ED clinical experience, and current employment in the ED. ED RNs used a standardized GOC questionnaire. Patient inclusion criteria included age ≥18 years and one or more of the following: chronic kidney disease ≥ stage III, congestive heart failure with an ejection fraction ≤ 40%, chronic obstructive pulmonary disease with home oxygen use, and/or malignancy with metastasis. GOC conversations were recorded in the electronic medical record (EMR). Physician Orders for Life-Sustaining Treatment (POLST) forms were completed as appropriate. Select individual patient data for the 12 months prior to the conversation were compared with the following 12 months. Results: Over 6 months, 94 of 133 patients who were approached consented to the GOC discussion with the RN. All 94 enrolled patients had their GOC recorded into the EMR. One-third already had a completed POLST form prior to ED arrival. 50% without a POLST on ED arrival left with a completed POLST. Eighty-four patients survived the index visit and 46 patients survived to study completion. Patient satisfaction with the interaction was high: In the cohort who survived past the index visit, 95% rated their experience at 4/5 or 5/5 (Likert scale, 5: strongly agree, 1: strongly disagree). In the survival-to-study completion cohort, 100% rated their experience as 4/5 or 5/5. Subsequent median ED visits decreased by 15% (1.0-4.0 interquartile range). There were no statistically significant changes in hospitalizations (both decreased by 25%, 0-3.0) or intensive care unit admissions (0%, 0-0). Conclusions: An ED RN-led GOC conversation had high patient satisfaction and 100% GOC documentation in the EMR. There was a significant increase in ED POLST form completion. There were no significant changes noted in subsequent hospitalizations, length of hospitalization, or intensive care unit utilization.
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Affiliation(s)
- Suzanne Bigelow
- Emergency Medicine, Providence Regional Medical Center Everett, Everett, WA, USA
- Elson School of Medicine, Washington State University, Spokane, WA, USA
| | - Ron Medzon
- Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Solomont Center for Clinical Simulation and Nursing Education, Boston Medical Center, Boston, Massachusetts, USA
| | - Mari Siegel
- Department of Emergency Medicine, Palliative Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Ruyun Jin
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence Research Network, Portland, OR, USA
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2
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Alshehri HH, Wolf A, Öhlén J, Olausson S. Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study. Glob Qual Nurs Res 2022; 9:23333936221138077. [PMID: 36507302 PMCID: PMC9729985 DOI: 10.1177/23333936221138077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/24/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022] Open
Abstract
There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.
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Affiliation(s)
- Hanan Hamdan Alshehri
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Hanan Hamdan Alshehri, University of Gothenburg Sahlgrenska Academy, Box 457 405 30 Göteborg, Goteborg 405 30, Sweden. Emails: ;
| | - Axel Wolf
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital/Östra, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Palliative Centre, Sahlgrenska University Hospital Region Västra Götaland, Sweden
| | - Sepideh Olausson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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3
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Kowalczys A, Bohdan M, Wilkowska A, Pawłowska I, Pawłowski L, Janowiak P, Jassem E, Lelonek M, Gruchała M, Sobański P. Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease—Integration of palliative care with disease-specific care: From guidelines to practice. Front Cardiovasc Med 2022; 9:895495. [PMID: 36237915 PMCID: PMC9551106 DOI: 10.3389/fcvm.2022.895495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the leading global epidemiological, clinical, social, and economic burden. Due to similar risk factors and overlapping pathophysiological pathways, the coexistence of these two diseases is common. People with severe COPD and advanced chronic HF (CHF) develop similar symptoms that aggravate if evoking mechanisms overlap. The coexistence of COPD and CHF limits the quality of life (QoL) and worsens symptom burden and mortality, more than if only one of them is present. Both conditions progress despite optimal, guidelines directed treatment, frequently exacerbate, and have a similar or worse prognosis in comparison with many malignant diseases. Palliative care (PC) is effective in QoL improvement of people with CHF and COPD and may be a valuable addition to standard treatment. The current guidelines for the management of HF and COPD emphasize the importance of early integration of PC parallel to disease-modifying therapies in people with advanced forms of both conditions. The number of patients with HF and COPD requiring PC is high and will grow in future decades necessitating further attention to research and knowledge translation in this field of practice. Care pathways for people living with concomitant HF and COPD have not been published so far. It can be hypothesized that overlapping of symptoms and similarity in disease trajectories allow to draw a model of care which will address symptoms and problems caused by either condition.
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Affiliation(s)
- Anna Kowalczys
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
- *Correspondence: Anna Kowalczys,
| | - Michał Bohdan
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Iga Pawłowska
- Department of Pharmacology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Leszek Pawłowski
- Department of Palliative Medicine, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Piotr Janowiak
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Ewa Jassem
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Gruchała
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Sobański
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Schwyz Hospital, Schwyz, Switzerland
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4
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Bharadwaj P, Taylor S, Randhawa MS, Gill G, Solomon A. Identifying the Time of Intervention When Managing Populations: Know Your Data. J Palliat Med 2021; 24:1592-1593. [PMID: 34726518 DOI: 10.1089/jpm.2021.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Parag Bharadwaj
- Palliative Care, MemorialCare Medical Group, Fountain Valley, California, USA
| | - Sarah Taylor
- MemorialCare Medical Foundation, Fountain Valley, California, USA
| | | | - Gagandeep Gill
- MemorialCare Medical Foundation, Fountain Valley, California, USA
| | - Adam Solomon
- MemorialCare Medical Foundation, Fountain Valley, California, USA
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5
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Yang GM, Zhou S, Xu Z, Goh SS, Zhu X, Chong DQ, Tan DS, Kanesvaran R, Yee AC, Neo PS, Cheung YB. Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial. Palliat Med 2021; 35:1578-1589. [PMID: 34524044 DOI: 10.1177/02692163211022957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. AIM To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. DESIGN An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. SETTING/PARTICIPANTS Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. RESULTS A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models. CONCLUSIONS The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.
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Affiliation(s)
- Grace M Yang
- National Cancer Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Sengkang General Hospital, Singapore
| | - Siqin Zhou
- National Cancer Centre Singapore, Singapore
| | - Zhizhen Xu
- National Cancer Centre Singapore, Singapore
| | | | - Xia Zhu
- National Cancer Centre Singapore, Singapore
| | | | | | | | | | | | - Yin-Bun Cheung
- Duke-NUS Medical School, Singapore.,Tampere University, Finland
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6
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Mir WAY, Siddiqui AH, Paul V, Habib S, Reddy S, Gaire S, Shrestha DB. Palliative Care and Chronic Obstructive Pulmonary Disease (COPD) Readmissions: A Narrative Review. Cureus 2021; 13:e16987. [PMID: 34540390 PMCID: PMC8421707 DOI: 10.7759/cureus.16987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Despite all the advances in the treatment and management of chronic obstructive pulmonary disease (COPD), COPD readmissions remain a major challenge nationwide. Increasing evidence suggests that palliative care involvement with a holistic approach towards end-of-life care can significantly improve outcomes related to the quality of life and survival for late-stage cancers and chronic progressive illnesses like COPD, chronic heart failure, and end-stage renal disease. Some studies have attempted to evaluate an association between the involvement of palliative care and readmission reduction, the effect of which remains elusive, especially with regards to COPD readmissions. This review examined the existing literature to analyze the relationship between palliative care involvement for COPD patients and its effect on COPD readmissions.
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Affiliation(s)
| | - Abdul Hasan Siddiqui
- Pulmonary and Critical Care Medicine, University of Illinois at Urbana-Champaign, Champaign, USA
| | - Vishesh Paul
- Pulmonary and Critical Care Medicine, Carle Foundation Hospital, Urbana, USA
| | - Saad Habib
- Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Shravani Reddy
- Department of Internal Medicine, Rush University Medical Center, Chicago, USA
| | - Suman Gaire
- Department of Emergency Medicine, Palpa Hospital, Palpa, NPL
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7
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Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice. Dimens Crit Care Nurs 2021; 39:219-235. [PMID: 32467406 DOI: 10.1097/dcc.0000000000000423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting. OBJECTIVES This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines. METHODS This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time. RESULTS Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285). CONCLUSION This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.
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8
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Janberidze E, Poláková K, Bankovská Motlová L, Loučka M. Impact of palliative care consult service in inpatient hospital setting: a systematic literature review. BMJ Support Palliat Care 2020; 11:351-360. [PMID: 32958505 DOI: 10.1136/bmjspcare-2020-002291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/08/2020] [Accepted: 08/14/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Despite a number of studies on effectiveness of palliative care, there is a lack of complex updated review of the impact of in-hospital palliative care consult service. The objective is to update information on the impact of palliative care consult service in inpatient hospital setting. METHODS This study was a systematic literature review, following the standard protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Joanna Briggs Institute tools) to ensure the transparent and robust review procedure. The effect of palliative care consult service was classified as being associated with improvement, no difference, deterioration or mixed results in specific outcomes. PubMed, Scopus, Academic Search Ultimate and SocINDEX were systematically searched up to February 2020. Studies were included if they focused on the impact of palliative care consult service caring for adult palliative care patients and their families in inpatient hospital setting. RESULTS After removing duplicates, 959 citations were screened of which 49 full-text articles were retained. A total of 28 different outcome variables were extracted. 18 of them showed positive effects within patient, family, staff and healthcare system domains. No difference was observed in patient survival and depression. Inconclusive results represented patient social support and staff satisfaction with care. CONCLUSIONS Palliative care consult service has a number of positive effects for patients, families, staff and healthcare system. More research is needed on factors such as patient spiritual well-being, social support, performance, family understanding of patient diagnosis or staff stress.
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Affiliation(s)
- Elene Janberidze
- Department of Psychiatry and Medical Psychology - Division of Medical Psychology, Charles University, Third Faculty of Medicine, Praha, Czech Republic .,Department of Gerontology and Palliative Medicine, Iv. Javakhishvili Tbilisi State University/Institute of Morphology, Tbilisi, Georgia.,Faculty of Medicine, School of Health Sciences and Public Health, University of Georgia, Tbilisi, Georgia
| | - Kristýna Poláková
- Department of Psychiatry and Medical Psychology - Division of Medical Psychology, Charles University, Third Faculty of Medicine, Praha, Czech Republic.,Center for Palliative Care, Praha, Czech Republic
| | - Lucie Bankovská Motlová
- Department of Psychiatry and Medical Psychology - Division of Medical Psychology, Charles University, Third Faculty of Medicine, Praha, Czech Republic
| | - Martin Loučka
- Department of Psychiatry and Medical Psychology - Division of Medical Psychology, Charles University, Third Faculty of Medicine, Praha, Czech Republic.,Center for Palliative Care, Praha, Czech Republic
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9
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Challenges of Promoting Uniformity in Programs within a Health Care System. J Palliat Med 2020; 23:8-9. [DOI: 10.1089/jpm.2019.0404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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10
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Tyacke MH, Guttormson JL, Garnier-Villarreal M, Schroeter K, Peltier W. Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life. Heart Lung 2019; 49:123-131. [PMID: 31492522 DOI: 10.1016/j.hrtlng.2019.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/30/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older adults prefer comfort over life-sustaining care. Decreased intensity of care is associated with improved quality of life at the end-of-life (EOL). OBJECTIVES This study explored the association between advance directives (ADs) and intensity of care in the acute care setting at the EOL for older adults. METHODS A retrospective, correlational study of older adult decedents (N = 496) was conducted at an academic medical center. Regression analyses explored the association between ADs and intensity of care. RESULTS Advance directives were not independently predictive of aggressive care but were independently associated with referrals to palliative care and hospice; however, effect sizes were small, and the timing of referrals was late. CONCLUSION The ineffectiveness of ADs to reduce aggressive care or promote timely referrals to palliative and hospice services, emphasizes persistent inadequacies related to EOL care. Research is needed to understand if this failure is provider-driven or a flaw in the documents themselves.
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Affiliation(s)
- Marsha H Tyacke
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | - Jill L Guttormson
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | | | - Kathryn Schroeter
- Marquette University, College of Nursing, PO Box 1881, Milwaukee, WI 53201, United States.
| | - Wendy Peltier
- Medical College of Wisconsin, CLCC, Clinical Cancer Center, 9200 W Wisconsin Ave, Milwaukee, WI 53226, United States.
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11
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Electronic Health Record Mortality Prediction Model for Targeted Palliative Care Among Hospitalized Medical Patients: a Pilot Quasi-experimental Study. J Gen Intern Med 2019; 34:1841-1847. [PMID: 31313110 PMCID: PMC6712114 DOI: 10.1007/s11606-019-05169-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/11/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Development of electronic health record (EHR) prediction models to improve palliative care delivery is on the rise, yet the clinical impact of such models has not been evaluated. OBJECTIVE To assess the clinical impact of triggering palliative care using an EHR prediction model. DESIGN Pilot prospective before-after study on the general medical wards at an urban academic medical center. PARTICIPANTS Adults with a predicted probability of 6-month mortality of ≥ 0.3. INTERVENTION Triggered (with opt-out) palliative care consult on hospital day 2. MAIN MEASURES Frequencies of consults, advance care planning (ACP) documentation, home palliative care and hospice referrals, code status changes, and pre-consult length of stay (LOS). KEY RESULTS The control and intervention periods included 8 weeks each and 138 admissions and 134 admissions, respectively. Characteristics between the groups were similar, with a mean (standard deviation) risk of 6-month mortality of 0.5 (0.2). Seventy-seven (57%) triggered consults were accepted by the primary team and 8 consults were requested per usual care during the intervention period. Compared to historical controls, consultation increased by 74% (22 [16%] vs 85 [63%], P < .001), median (interquartile range) pre-consult LOS decreased by 1.4 days (2.6 [1.1, 6.2] vs 1.2 [0.8, 2.7], P = .02), ACP documentation increased by 38% (23 [17%] vs 37 [28%], P = .03), and home palliative care referrals increased by 61% (9 [7%] vs 23 [17%], P = .01). There were no differences between the control and intervention groups in hospice referrals (14 [10] vs 22 [16], P = .13), code status changes (42 [30] vs 39 [29]; P = .81), or consult requests for lower risk (< 0.3) patients (48/1004 [5] vs 33/798 [4]; P = .48). CONCLUSIONS Targeting hospital-based palliative care using an EHR mortality prediction model is a clinically promising approach to improve the quality of care among seriously ill medical patients. More evidence is needed to determine the generalizability of this approach and its impact on patient- and caregiver-reported outcomes.
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12
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Bell D, Ruttenberg MB, Chai E. Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department. Clin Geriatr Med 2019; 34:453-467. [PMID: 30031427 DOI: 10.1016/j.cger.2018.04.008] [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: 11/28/2022]
Abstract
Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.
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Affiliation(s)
- Daniel Bell
- Department of Emergency Medicine, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30322, USA.
| | - Margaret Brungraber Ruttenberg
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Emily Chai
- Geriatrics and Palliative Medicine Inpatient Services, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1970, New York, NY 10029, USA
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13
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Barkley JE, McCall A, Maslow AL, Skudlarska BA, Chen X. Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality. J Palliat Med 2019; 22:393-399. [DOI: 10.1089/jpm.2018.0399] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- John E. Barkley
- Continuing Care Services, Atrium Health, Charlotte, North Carolina
| | - Andrea McCall
- Quality Division, Atrium Health, Charlotte, North Carolina
| | - Andréa L. Maslow
- Information and Analytics Services, Atrium Health, Charlotte, North Carolina
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14
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Druml W, Druml C. [Overtreatment in intensive care medicine]. Med Klin Intensivmed Notfmed 2019; 114:194-201. [PMID: 30918983 DOI: 10.1007/s00063-019-0548-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/02/2019] [Indexed: 12/31/2022]
Abstract
Overtreatment, which is therapy that is neither indicated nor desired by the patient ("non-beneficial"), presents an inherent and huge problem of modern medicine and intensive care medicine in particular. Overtreatment concerns all aspects of intensive care medicine, may start already before admission at the emergency scene, the inappropriate admission to the intensive care unit, overuse in diagnostics and especially in blood sampling, in invasive procedures and in organ support therapies. It manifests itself as "too much" in sedation, relaxation, volume therapy, hemodynamic support, blood products, antibiotics and other drugs and nutrition. Most importantly, overtreatment concerns the care of the patients at the end of life when a causal therapy is no longer available. Overtreatment also has important ethical implications and violates the four fundamental principles of medical ethics. It disregards the autonomy, dignity and integrity of the patient, is by definition nonbeneficial and increases pain, suffering, prolongs dying, increases sorrow of relatives, imposes frustration for the caregivers, disregards distributive justice and harms society in general by wasting principally limited resources. Overtreatment has also become an important legal issue and because of imposing inappropriate suffering may lead to prosecution. Overtreatment is poor medicine, is no trivial offence, all must continuously work together to reduce or avoid overtreatment.
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Affiliation(s)
- W Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - C Druml
- Ethik, Sammlungen und Geschichte der Medizin, Medizinische Universität Wien, Währinger Gürtel 25, 1090, Wien, Österreich.
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15
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Hoerger M, Perry LM, Korotkin BD, Walsh LE, Kazan AS, Rogers JL, Atiya W, Malhotra S, Gerhart JI. Statewide Differences in Personality Associated with Geographic Disparities in Access to Palliative Care: Findings on Openness. J Palliat Med 2019; 22:628-634. [PMID: 30615552 DOI: 10.1089/jpm.2018.0206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Geographic disparities in access to palliative care cause unnecessary suffering near the end-of-life in low-access U.S. states. The psychological mechanisms accounting for state-level variation are poorly understood. Objective: To examine whether statewide differences in personality account for variation in palliative care access. Design: We combined 5 state-level datasets that included the 50 states and national capital. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. State-level personality differences in openness, conscientiousness, agreeableness, neuroticism, and extraversion were identified in a report on 619,387 adults. The Census and Gallup provided covariate data. Regression analyses examined whether state-level personality predicted state-level palliative care access, controlling for population size, age, gender, race/ethnicity, socioeconomic status, and political views. Sensitivity analyses controlled for rurality, nonprofit status, and hospital size. Results: Palliative care access was higher in states that were older, less racially diverse, higher in socioeconomic status, more liberal, and, as hypothesized, higher in openness. In regression analyses accounting for all predictors and covariates, higher openness continued to account for better state-level access to palliative care (β = 0.428, p = 0.008). Agreeableness also emerged as predicting better access. In sensitivity analyses, personality findings persisted, and less rural states and those with more nonprofits had better access. Conclusions: Palliative care access is worse in states lower in openness, meaning where residents are more skeptical, traditional, and concrete. Personality theory offers recommendations for palliative care advocates communicating with administrators, legislators, philanthropists, and patients to expand access in low-openness states.
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Affiliation(s)
- Michael Hoerger
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,2 Section of Hematology and Medical Oncology, Department of Medicine, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Laura M Perry
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Brittany D Korotkin
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Leah E Walsh
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Adina S Kazan
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - James L Rogers
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Wasef Atiya
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Sonia Malhotra
- 3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana.,4 Section of Palliative Medicine, Department of General Internal Medicine and Geriatrics, Tulane University, New Orleans, Louisiana
| | - James I Gerhart
- 5 Department of Psychology, Central Michigan University, Mount Pleasant, Michigan
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16
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The use of hospital-based services by heart failure patients in the last year of life: a discussion paper. Heart Fail Rev 2018; 24:199-207. [DOI: 10.1007/s10741-018-9751-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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17
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Palliative care in heart failure. Trends Cardiovasc Med 2018; 28:445-450. [PMID: 29735287 DOI: 10.1016/j.tcm.2018.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/04/2018] [Accepted: 02/15/2018] [Indexed: 12/31/2022]
Abstract
Palliative care (PC) is now recommended by all major cardiovascular societies for advanced heart failure (HF). PC is a philosophy of care that uses a holistic approach to address physical, psychosocial, and spiritual needs in patients with a terminal disease process. In HF, PC has been shown to improve symptoms and quality of life, facilitate advanced care planning, decrease hospital readmissions, and decrease hospital-associated healthcare costs. Although PC is still underutilized in HF, uptake is increasing. Specific strategies for successfully implementing PC in HF include early PC involvement, multidisciplinary collaboration, exploring patient values for end-of-life care, medical therapy (including both the addition of symptom-directed medications, as well as the removal of life-prolonging medications), and considerations regarding device therapy and mechanical support. Barriers to PC in HF include difficulties predicting the disease trajectory, patient and physician misconceptions, and lack of PC-trained physicians. Moving forward, PC will continue to be a key part of advanced HF care as our knowledge of this area grows.
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18
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Ziegler LE, Craigs CL, West RM, Carder P, Hurlow A, Millares-Martin P, Hall G, Bennett MI. Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study. BMJ Open 2018; 8:e018284. [PMID: 29386222 PMCID: PMC5829853 DOI: 10.1136/bmjopen-2017-018284] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This study aimed to establish the association between timing and provision of palliative care (PC) and quality of end-of-life care indicators in a population of patients dying of cancer. SETTING This study uses linked cancer patient data from the National Cancer Registry, the electronic medical record system used in primary care (SystmOne) and the electronic medical record system used within a specialist regional cancer centre. The population resided in a single city in Northern England. PARTICIPANTS Retrospective data from 2479 adult cancer decedents who died between January 2010 and February 2012 were registered with a primary care provider using the SystmOne electronic health record system, and cancer was certified as a cause of death, were included in the study. RESULTS Linkage yielded data on 2479 cancer decedents, with 64.5% who received at least one PC event. Decedents who received PC were significantly more likely to die in a hospice (39.4% vs 14.5%, P<0.005) and less likely to die in hospital (23.3% vs 40.1%, P<0.05), and were more likely to receive an opioid (53% vs 25.2%, P<0.001). PC initiated more than 2 weeks before death was associated with avoiding a hospital death (≥2 weeks, P<0.001), more than 4 weeks before death was associated with avoiding emergency hospital admissions and increased access to an opioid (≥4 weeks, P<0.001), and more than 33 weeks before death was associated with avoiding late chemotherapy (≥33 weeks, no chemotherapy P=0.019, chemotherapy over 4 weeks P=0.007). CONCLUSION For decedents with advanced cancer, access to PC and longer duration of PC were significantly associated with better end-of-life quality indicators.
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Affiliation(s)
- Lucy E Ziegler
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cheryl L Craigs
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert M West
- Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Carder
- NHS Bradford Districts Clinical Commissioning Group, Bradford, UK
| | - Adam Hurlow
- Leeds General Infirmary, Leeds, UK
- Specialist Palliative Care Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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19
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O'Connor NR, Junker P, Appel SM, Stetson RL, Rohrbach J, Meghani SH. Palliative Care Consultation for Goals of Care and Future Acute Care Costs: A Propensity-Matched Study. Am J Hosp Palliat Care 2017; 35:966-971. [PMID: 29169247 DOI: 10.1177/1049909117743475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Hospitals are under increasing pressure to manage costs across multiple episodes of care. Most studies of the financial impact of palliative care have focused on costs during a single hospitalization. OBJECTIVE To compare future acute health-care costs and utilization between patients who received inpatient palliative care consultation for goals of care (Palliative Care Service [PCS]) and a propensity-matched cohort of patients who did not receive palliative care consultation (non-PCS) in a single academic medical center. METHODS Data were extracted from the hospital's electronic records for admissions and discharges between July 2014 and October 2016. A stratified propensity score matching was used to account for nonrandom assignment and potential inherent differences between PCS and non-PCS groups using variables of theoretical interest: age, gender, race, diagnosis, risk of mortality, and prior acute care costs. RESULTS The analytical sample for this study included 41 363 patients (PCS = 1853; non-PCS = 39 510). Future acute care costs were significantly higher in the non-PCS group after propensity score matching (highest tier = US$15 654 vs US$8831; second highest tier = US$12 200 vs US$5496; P = .0001). The non-PCS group also had significantly higher future acute care utilization across all propensity tiers and outcomes including 30-day readmission ( P = .0001), number of future hospital days ( P = .0001), and number of future intensive care unit days ( P = .0001). CONCLUSION Palliative care consultations for goals of care may decrease future health-care utilization with cost savings that persist into future hospitalizations.
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Affiliation(s)
- Nina R O'Connor
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Paul Junker
- 2 Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Scott M Appel
- 3 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman Health System, Philadelphia, PA, USA
| | - Robert L Stetson
- 4 Corporate Office of Strategic Decision Support, University of Pennsylvania, Philadelphia Health System, PA, USA
| | - Jeffrey Rohrbach
- 2 Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Salimah H Meghani
- 5 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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20
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Wiskar K, Celi LA, Walley KR, Fruhstorfer C, Rush B. Inpatient palliative care referral and 9-month hospital readmission in patients with congestive heart failure: a linked nationwide analysis. J Intern Med 2017; 282:445-451. [PMID: 28741859 DOI: 10.1111/joim.12657] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE End-stage heart failure (HF) is characterized by high symptom burden and frequent hospitalization. Palliative care (PC) is recommended for advanced HF, and there is some evidence in other diseases that this may reduce readmission rates. We attempted examine the association of an inpatient PC visit on hospital readmission for patients admitted with HF. METHODS Retrospective linked nationwide analysis from 2013 with 9-month follow-up for all hospital readmissions for patients admitted with HF exacerbations using the Nationwide Readmission Database (NRD). The NRD gathers all hospital admissions for patients from 22 states and tracks patients throughout the year, allowing for examination of readmission statistics. A propensity score model for PC visit was made, and patients were matched in a 1 : 1 fashion. RESULTS There were 102 746 patients who survived an admission for HF in the first 3 months of 2013. Of these, 2287 (2.2%) patients had a PC visit as inpatients. After matching based on propensity for a PC visit during the index hospitalization, 2282 patients who received a PC visit were matched to 2282 patients who did not. Those receiving a PC visit were less likely to be readmitted for HF (9.3% vs. 22.4%, P < 0.01) or for any cause (29.0% vs. 63.2%, P < 0.01) during the 9-month follow-up period. The average hospital charges during the follow-up period for the non-PC cohort were $77 643 per patient. The average charges for PC patients were $23 200 (P < 0.01). CONCLUSIONS Patients with HF who received an inpatient PC visit had significantly lower rates of all-cause and HF-specific readmission in the subsequent 9 months. Total 9-month hospital charges were also significantly lower for patients who received an inpatient PC visit.
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Affiliation(s)
- K Wiskar
- Department of Medicine, Division of General Internal Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - L A Celi
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K R Walley
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, BC, Canada
| | - C Fruhstorfer
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - B Rush
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, BC, Canada.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
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21
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22
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Using the Rothman Index and Length of Stay as a Trigger for Palliative Care in the Medical Intensive Care Unit and Step-Down Units. J Hosp Palliat Nurs 2017. [DOI: 10.1097/njh.0000000000000334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Haley EM, Meisel D, Gitelman Y, Dingfield L, Casarett DJ, O'Connor NR. Electronic Goals of Care Alerts: An Innovative Strategy to Promote Primary Palliative Care. J Pain Symptom Manage 2017; 53:932-937. [PMID: 28062333 DOI: 10.1016/j.jpainsymman.2016.12.329] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 11/20/2016] [Accepted: 12/23/2016] [Indexed: 01/13/2023]
Abstract
CONTEXT Given the shortage of palliative care specialists, strategies are needed to promote primary palliative care by nonpalliative care providers. Electronic reminders are frequently used in medicine to standardize practice, but their effectiveness in encouraging goals of care discussions is not well understood. OBJECTIVES To determine whether brief education and electronic alerts increase the frequency of goals of care discussions. METHODS All general medicine services at a large academic medical center were included. Each medicine team received brief education on rounds about goals of care communication tool. When a newly admitted patient met predefined criteria, an electronic alert that included the tool was sent to the patient's resident and attending physicians within 48 hours. RESULTS Of 352 admissions screened over a four-week period, 18% met one or more criteria. The combination of alerts and education increased documentation of goals of care in the medical record from 20.5% (15/73) to 44.6% (25/56) of patients (risk ratio 2.17, 95% CI 1.23-3.72). There were no significant changes in code status, noncode status limitations in care, or palliative care consultation. CONCLUSION The combination of brief education and electronic goals of care alerts significantly increased documented goals of care discussions. This intervention is simple and feasible in many settings, but larger studies are needed to determine impact on patient outcomes.
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Affiliation(s)
- Erin M Haley
- Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Deborah Meisel
- Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yevgeniy Gitelman
- Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Dingfield
- Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David J Casarett
- Department of Medicine at Duke University School of Medicine, Durham, North Carolina, USA
| | - Nina R O'Connor
- Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA. nina.o'
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24
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Dunn EJ, Markert R, Hayes K, McCollom J, Bains L, Kahlon D, Kumar G. The Influence of Palliative Care Consultation on Health-Care Resource Utilization During the Last 2 Months of Life: Report From an Integrated Palliative Care Program and Review of the Literature. Am J Hosp Palliat Care 2016; 35:117-122. [PMID: 28273754 DOI: 10.1177/1049909116683719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We reviewed 104 consecutive deaths of veterans receiving care in the Dayton VA Medical Center from October 10, 2015 to April 11, 2016. The purpose of our study was to test our hypothesis that palliative care consultation would be associated with reduced health care resource utilization for individuals approaching end of life. METHODS Medical records were reviewed and data entry recorded on a spreadsheet. Non-parametric statistical methods were used to compare four outcome variables from veterans with palliative care consultation (PCC) vs. those without PCC. These variables included the number of ED visits, hospitalizations, hospital days, and ICU days all during the last two months of life. Predictor variables included PCC vs. no PCC and PCC before vs. PCC during the last two months of life. The study sample was comprised of 102 patients after excluding two outlier cases with ethical challenges in surrogate decision-making. RESULTS Of the 102 consecutive veteran deaths, palliative care consultation was associated with a lower number of ICU days during the last two months of life. For 96 veterans with PCC, the frequency of ED visits and acute care hospitalizations, as well as the number of ICU and hospital days, were all significantly less after PCC compared to before PCC during the last two months of life. The timing of PCC had no effect on the outcomes of interest. CONCLUSION Palliative care consultation has a notable effect on health care resource utilization during the last two months of life.
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Affiliation(s)
- Edward J Dunn
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Ronald Markert
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Kathleen Hayes
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Joseph McCollom
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Loveleen Bains
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Damanjeet Kahlon
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Geetika Kumar
- 1 Dayton VA Medical Center, Dayton, OH, USA.,2 Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
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25
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Hua M, Li G, Clancy C, Morrison RS, Wunsch H. Validation of the V66.7 Code for Palliative Care Consultation in a Single Academic Medical Center. J Palliat Med 2016; 20:372-377. [PMID: 27925839 DOI: 10.1089/jpm.2016.0363] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown. OBJECTIVE To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation. DESIGN Retrospective cohort study. SETTING/SUBJECTS All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015. MEASUREMENTS Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record. RESULTS Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846 (1.8%) had usage of the V66.7 code. Sensitivity and specificity for the V66.7 code were 49.9% and 99.1%, respectively. Sensitivity was considerably higher for certain subgroups, such as patients with dementia (76.3%) and metastatic cancer (66.3%); addition of age restrictions further improved sensitivity while maintaining high specificity. Specificity was substantially lower for patients who died during hospitalization (sensitivity 53.9%, specificity 75.1%). CONCLUSIONS In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation. Appropriate use of this code for this purpose should take these characteristics into consideration.
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Affiliation(s)
- May Hua
- 1 Department of Anesthesiology, Columbia University , New York, New York.,2 Department of Epidemiology, Columbia University Mailman School of Public Health , New York, New York
| | - Guohua Li
- 2 Department of Epidemiology, Columbia University Mailman School of Public Health , New York, New York.,3 Department of Anesthesiology, Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons
| | - Caitlin Clancy
- 1 Department of Anesthesiology, Columbia University , New York, New York
| | - R Sean Morrison
- 4 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Hannah Wunsch
- 1 Department of Anesthesiology, Columbia University , New York, New York.,5 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre , Toronto, Ontario, Canada .,6 Department of Anesthesia, University of Toronto , Toronto, Ontario, Canada
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26
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George NR, Kryworuchko J, Hunold KM, Ouchi K, Berman A, Wright R, Grudzen CR, Kovalerchik O, LeFebvre EM, Lindor RA, Quest TE, Schmidt TA, Sussman T, Vandenbroucke A, Volandes AE, Platts-Mills TF. Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda. Acad Emerg Med 2016; 23:1394-1402. [PMID: 27611892 DOI: 10.1111/acem.13083] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.
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Affiliation(s)
- Naomi R. George
- Department of Emergency Medicine; Brown University; Providence RI
| | | | | | - Kei Ouchi
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA
| | - Amy Berman
- Hartford Program Officer/Patient Representative; New York NY
| | - Rebecca Wright
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | - Corita R. Grudzen
- Department of Emergency Medicine; NYU School of Medicine; New York NY
| | | | - Eric M. LeFebvre
- Department of Emergency Medicine, Geriatric Fellow; University of North Carolina-Chapel Hill; Chapel Hill NC
| | | | - Tammie E. Quest
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Terri A. Schmidt
- Departments of Emergency Medicine and Hematology/Oncology; Oregon Health and Science University; Portland OR
| | - Tamara Sussman
- School of Social Work; McGill University; Montreal Quebec Canada
| | | | | | - Timothy F. Platts-Mills
- Department of Emergency Medicine and Department of Anesthesiology; University of North Carolina-Chapel Hill; Chapel Hill NC
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27
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Evaluation of a Multifaceted Educational Intervention to Improve Palliative Care in the Intensive Care Unit. J Hosp Palliat Nurs 2016. [DOI: 10.1097/njh.0000000000000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Jubelt LE, Elitzer AI, Kyriacou JP, Reich DL. Healthcare Reform and the Cardiac Anesthesiologist/Intensivist: Challenges Ahead. J Cardiothorac Vasc Anesth 2016; 31:329-333. [PMID: 27692905 DOI: 10.1053/j.jvca.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Lindsay E Jubelt
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Amy I Elitzer
- The Mount Sinai Hospital, Mount Sinai Health System, New York, NY
| | | | - David L Reich
- The Mount Sinai Hospital, Mount Sinai Health System, New York, NY; Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
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