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Gupta AK, Jannes J, Kleinig T, Goh R, Bacchi S, Ovenden CD, To MS, Kovoor JG, Gupta AK, Jannes J, Kleinig T. Resuscitation orders demonstrate differences by gender, stroke type and intervention. J Stroke Cerebrovasc Dis 2024:107881. [PMID: 39033945 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 07/07/2024] [Accepted: 07/18/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND AND PURPOSE Resuscitation orders describe individual preferences and types of intervention, such as suitability for cardiopulmonary resuscitation (CPR), that may provide benefit in the event of critical deterioration. The purpose of this study was to examine stroke inpatient resuscitation order completion and content. METHODS This retrospective cohort study examined resuscitation orders in consecutive individuals admitted to a tertiary stroke centre over a 21-month period. Multivariable logistic regression was used to identify factors associated with resuscitation order completion and content. RESULTS 1924 individuals were included in the study. The proportion of individuals who had resuscitation orders completed was 37.4%. Several factors were associated with an increased likelihood of resuscitation order completion including having received endovascular thrombectomy (p=0.013) and having intracerebral haemorrhage (p=0.001). Females were more likely to have a resuscitation order that is not for CPR (p=0.021, OR 95%CI 1.080-2.542). Patients with intracerebral haemorrhage were also more likely to be not for CPR (p=0.037, OR 95%CI 1.039-3.353). CONCLUSIONS Disparities exist in resuscitation order completion and content based on demographic and stroke characteristics. Further research is required to identify the reasons for these differences and to optimise resuscitation order completion.
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Affiliation(s)
- Aashray K Gupta
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia
| | - Jim Jannes
- Lyell McEwin Hospital, Elizabeth Vale SA 5112, Australia; Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Timothy Kleinig
- Lyell McEwin Hospital, Elizabeth Vale SA 5112, Australia; Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Rudy Goh
- Lyell McEwin Hospital, Elizabeth Vale SA 5112, Australia; Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia.
| | - Stephen Bacchi
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; Flinders Medical Centre, Bedford Park SA 5042, Australia; University of Adelaide, Adelaide SA 5005, Australia.
| | - Christopher D Ovenden
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia.
| | - Minh-Son To
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park SA 5042, Australia.
| | - Joshua G Kovoor
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia.
| | | | - Jim Jannes
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia.
| | - Timothy Kleinig
- Royal Adelaide Hospital, Adelaide SA 5000, Australia; University of Adelaide, Adelaide SA 5005, Australia.
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2
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Sulaiman SA, Quazi MA, Sohail AH, Goyal A, Jawadi MA, Maan S, Sheikh AB. Gender and Racial Differences in the Provision of Palliative Care Services Among Critically ill Necrotizing Fasciitis and Septic Shock Geriatric Patients: Analysis of a Nationwide Database in the United States. Surg Infect (Larchmt) 2024. [PMID: 38957958 DOI: 10.1089/sur.2024.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
Introduction: Necrotizing fasciitis (NF) and sepsis shock (SS) are both severe and life-threatening conditions requiring specialized care, including palliative care (PC), to optimize comfort. However, data on the utilization of PC in this population, including racial and gender differences, are limited. Methods: We used the National Inpatient Sample (NIS) database from 2016 to 2020 to extract data on patients with NF and SS as well as PC utilization. Chi-squared tests and multivariate linear regression models were utilized to analyze relationships between categorical and continuous variables, respectively. Multivariable logistic regression was used to determine adjusted odds ratios (aORs) and 95% confidence intervals (CI) for various outcomes among various gender and racial groups. Mann-Kendall trend test was used to assess mortality trends over time. Results: Among the 11,260 patients with NF and SS, 2,645 received PC whereas 8,615 did not. Female patients had significantly higher odds of receiving PC versus males (aOR: 1.42, 95% CI 1.27-1.58). No significant racial differences in PC utilization were observed. Patients receiving PC had higher odds of in-hospital mortality (aOR: 1.18, 95% CI 1.03-1.35). No significant trend in in-hospital deaths was observed over the study period. PC was associated with significantly shorter length-of-stay and lower costs. Conclusion: Our study provides comprehensive insights, and identifies gender differences in PC utilization in NF and SS patients. Further research must aim to refine delivery strategies and address potential differences in PC.
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Affiliation(s)
- Samia Aziz Sulaiman
- Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | - Mohammed A Quazi
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Soban Maan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Abu Baker Sheikh
- Department of Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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3
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Minami CA, Jin G, Freedman RA, Schonberg MA, King TA, Mittendorf EA. Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor-positive breast cancer: A retrospective population-based cohort study. J Geriatr Oncol 2024; 15:101795. [PMID: 38759256 PMCID: PMC11225423 DOI: 10.1016/j.jgo.2024.101795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION We sought to determine how considerations specific to older adults impact between- and within-surgeon variation in axillary surgery use in women ≥70 years with T1N0 HR+ breast cancer. MATERIALS AND METHODS Females ≥70 years with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013 to 2015 in SEER-Medicare were identified and linked to the American Medical Association Masterfile. The outcome of interest was axillary surgery. Key patient-level variables included the Charlson Comorbidity Index (CCI) score, frailty (based on a claims-based frailty index score), and age (≥75 vs <75). Multilevel mixed models with surgeon clusters were used to estimate the intracluster correlation coefficient (ICC) (between-surgeon variance), with 1-ICC representing within-surgeon variance. RESULTS Of the 4410 participants included, 6.1% had a CCI score of ≥3, 20.7% were frail, and 58.3% were ≥ 75 years; 86.1% underwent axillary surgery. No surgeon omitted axillary surgery in all patients, but 42.3% of surgeons performed axillary surgery in all patients. In the null model, 10.5% of the variance in the axillary evaluation was attributable to between-surgeon differences. After adjusting for CCI score, frailty, and age in mixed models, between-surgeon variance increased to 13.0%. DISCUSSION In this population, axillary surgery varies more within surgeons than between surgeons, suggesting that surgeons are not taking an "all-or-nothing" approach. Comorbidities, frailty, and age accounted for a small proportion of the variation, suggesting nuanced decision-making may include additional, unmeasured factors such as differences in surgeon-patient communication.
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Affiliation(s)
- Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Mara A Schonberg
- Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Prasitlumkum N, Chokesuwattanaskul R, Kaewput W, Thongprayoon C, Cheungpasitporn W, Jongnarangsin K, Nademanee K. Sex differences in clinical characteristics, management, and outcomes in patients admitted for ventricular tachycardia: 2016-2018. J Cardiovasc Electrophysiol 2023; 34:2086-2094. [PMID: 37554118 DOI: 10.1111/jce.16031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/10/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION The concurrent data on sex disparities in VT management and outcomes have remained unclear. Therefore, our objective was to determine the impact of sex on ventricular tachycardia (VT) management and outcomes in patients admitted with VT, dervied from the US National Inpatient Sample database (NIS). METHODS We used data from the US NIS to identify hospitalized adult patients who were admitted with VT between 2016 and 2018. Regression analysis was conducted to evaluate the impact of sex on VT management, in-hospital mortality, complications, length of stay, and hospitalization costs. RESULTS Of the database, a total of 146 070 patients, who were primarily hospitalized for VT, were approximated. Among these, women comprised 25.5%; they were significantly younger and had fewer comorbidities. Of procedural aspects, women were less likely to receive an angiogram, mechanical support, implantable cardioverter-defibrillator implantation, and VT ablation compared to men. Notably, women were associated with higher do-not-resuscitate rates and in-hospital cardiac arrests than men. No differences in in-hospital mortality and cardiogenic shock were observed between men and women (p > .05). Length of stay was significantly longer for women, while no differences in hospital costs were observed in both sexes. CONCLUSION Significant sex disparities in management and outcomes were observed in admitted patients with VT. Our results reflect the need for further studies to explore factors causing such diversities.
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Affiliation(s)
- Narut Prasitlumkum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronpichai Chokesuwattanaskul
- Department of Medicine, Division of Cardiovascular Medicine, Cardiac Center, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Center of Excellence in Arrhythmia Research Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | | | - Krit Jongnarangsin
- Division of Cardiac Electrophysiology, University of Michigan Health Care, Ann Arbor, Michigan, USA
| | - Koonlawee Nademanee
- Department of Medicine, Faculty of Medicine, Center of Excellence in Arrhythmia Research Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
- Pacific Rim Electrophysiology Research Institute, Bumrungrad Hospital, Bangkok, Thailand
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Webber C, Hafid S, Gayowsky A, Howard M, Tanuseputro P, Jones A, Scott MM, Hsu AT, Downar J, Manuel D, Conen K, Isenberg SR. End-of-life interventions in patients with cancer. BMJ Support Palliat Care 2023:spcare-2023-004222. [PMID: 37536756 DOI: 10.1136/spcare-2023-004222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site. METHODS We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site. RESULTS Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates. CONCLUSIONS Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shuaib Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aaron Jones
- ICES, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mary M Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, Walker Family Cancer Centre and Niagara Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Benoit DD, Vanheule S, Manesse F, Anseel F, De Soete G, Goethals K, Lievrouw A, Vansteelandt S, De Haan E, Piers R. Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial. PLoS One 2023; 18:e0281447. [PMID: 36943825 PMCID: PMC10030010 DOI: 10.1371/journal.pone.0281447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/18/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.
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Affiliation(s)
- Dominique D. Benoit
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
| | - Stijn Vanheule
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Frank Manesse
- Independent, Conversio, Gent, Belgium
- Kets de Vries Institute, London, United Kingdom
| | - Frederik Anseel
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | - Geert De Soete
- Ghent University Faculty of Psychology and Educational Sciences, Gent, Belgium
| | | | - An Lievrouw
- Intensive Care Medicine, University Hospital Ghent, Gent, Belgium
- Ghent University Hospital Cancer Centre, Gent, Belgium
| | - Stijn Vansteelandt
- Faculty of Applied Mathematics, Computer Sciences and Statistics, Ghent University Faculty of Sciences, Gent, Belgium
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Erik De Haan
- Hult International Business School Ashridge Centre for Coaching, Berkhamsted, United Kingdom
- VU Amsterdam School of Business and Economics, Amsterdam, The Netherlands
| | - Ruth Piers
- Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
- Ghent University Hospital Geriatrics, Gent, Belgium
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Jönsson N, Pettersson N, Asplund P, Bremer A, Lehtipalo S, Hessulf F. Factors associated with treatment limitations in two Swedish intensive care units: Prevalence and patient involvement. Acta Anaesthesiol Scand 2023; 67:339-346. [PMID: 36534119 DOI: 10.1111/aas.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
The aim was to study the prevalence, documentation, and patient involvement in treatment limitations (TLs) in two Swedish intensive care units (ICUs). All patients admitted to the ICUs of two Swedish regional hospitals in 2019 were screened for inclusion. Exclusion criteria included postanesthesia care <24 h. Patients were identified using the Swedish Intensive Care Registry (SIR) and data were extracted from SIR and hospital charts. Uni- and multivariable logistic analysis was performed to investigate associations with the presence of TLs. A total of 3090 patients were admitted to the two ICUs in 2019. After exclusion, 1019 patients were included in the study. 45.5% were women and the mean age was 62.9 years. 26.5% of the patients had one or several TLs. Age (OR 1.04 per one year increase 95% confidence interval (CI) 1.02-1.05), SAPS3-score (OR 1.08 per one unit increase 95% CI 1.06-1.09) and ICU length of stay (OR 1.11 per one day increase 95% CI 1.05-1.17) were independently associated with an increased likelihood of receiving a TL. 17% of the patients were involved in the decision-making process and in >30% of cases neither the patient nor next-of-kin were informed. Women were to a larger extent involved in the decision process than men (24.5 vs. 12.5% p < .05). When the intensivist documented why a TL was established, patient autonomy was four times more commonly stated as the motivation for the TL among women compared to men (15.5% vs. 3.8% p < .05). TLs were common in two Swedish ICUs but a substantial number of patients and next-of-kin were not involved in the decision-making process or informed of the decision. Women were more often than men engaged in the decision to establish a TL.
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Affiliation(s)
- Nino Jönsson
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Niklas Pettersson
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Peter Asplund
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Anders Bremer
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.,Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden.,Department of Ambulance Service, Region Kalmar County, Kalmar, Sweden
| | - Stefan Lehtipalo
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Fredrik Hessulf
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden.,Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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8
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Association between patient-surgeon race and gender concordance and patient-reported outcomes following breast cancer surgery. Breast Cancer Res Treat 2023; 198:167-175. [PMID: 36622543 DOI: 10.1007/s10549-022-06858-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/30/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Surgeon- and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between patient-surgeon race and gender concordance with QoL after breast reconstruction. METHODS We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no, intermediate, and perfect concordance. Multivariable regression was used to correlate postoperative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender and race concordance. RESULTS We identified 375 patients with a mean (± SD) age of 57.6 ± 11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender-discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (β, 2.60; 95% CI, 0.21-4.99, p = 0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (β, 2.14; 95% CI, 0.50-4.22, p = 0.045) than the race-discordant group. There were no significant associations observed between race or gender concordance and BREAST-Q performance. CONCLUSION Race-concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.
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Bacchi S, Gupta AK, Kovoor JG, Ovenden CD, To M, Jiang M, Goh R, Gluck S, Gilbert T. Gender and linguistic disparities in resuscitation orders: a multicentre retrospective cohort study. Intern Med J 2022; 52:1847-1848. [DOI: 10.1111/imj.15923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Stephen Bacchi
- Royal Adelaide Hospital Adelaide South Australia Australia
- University of Adelaide Adelaide South Australia Australia
- Flinders Health and Medical Research Institute Flinders University Adelaide South Australia Australia
| | - Aashray K. Gupta
- University of Adelaide Adelaide South Australia Australia
- Gold Coast University Hospital Gold Coast Queensland Australia
| | - Joshua G. Kovoor
- Royal Adelaide Hospital Adelaide South Australia Australia
- University of Adelaide Adelaide South Australia Australia
| | - Christopher D. Ovenden
- Royal Adelaide Hospital Adelaide South Australia Australia
- University of Adelaide Adelaide South Australia Australia
| | - Minh‐Son To
- Flinders Health and Medical Research Institute Flinders University Adelaide South Australia Australia
| | - Melinda Jiang
- Royal Adelaide Hospital Adelaide South Australia Australia
| | - Rudy Goh
- Royal Adelaide Hospital Adelaide South Australia Australia
- University of Adelaide Adelaide South Australia Australia
- Lyell McEwin Hospital Adelaide South Australia Australia
| | - Sam Gluck
- Royal Adelaide Hospital Adelaide South Australia Australia
- Lyell McEwin Hospital Adelaide South Australia Australia
| | - Toby Gilbert
- Royal Adelaide Hospital Adelaide South Australia Australia
- University of Adelaide Adelaide South Australia Australia
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10
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Abstract
Objective: Traditional gender norms and expectations may
disproportionately constrain in-home palliative care received by women. This
scoping review aims to canvass and evaluate the literature on gender disparities
in end of life care and explore relevant themes that could inform future
research and practice. Methods: A systematic search of MEDLINE,
OVID, COCHRANE, and EMBASE was conducted using MeSH terms palliative care,
palliative medicine, terminal care, or hospice care, combined with gender
equity, sex factors, sexism, or gender disparities. Articles were limited to
those in English (2010 to 2021), focusing on end of life care, gender roles,
patients, and caregivers. Results: Of 624 articles identified, 15
met inclusion criteria for critical appraisal using the AMSTAR checklist for
systematic reviews and NICE guidelines for quantitative and qualitative studies.
Most studies were of poor to moderate quality. Thematic analyses identified 6
major themes related to gender disparities: living situation, symptom
experience, care context, care preferences, caregiving, and coping strategies.
Conclusion: Larger scale research of better quality is needed
to fully characterize gender disparities in end of life care and understand how
physicians might mitigate these disparities by building awareness of personal
gender biases, providing support to families, educating them, and initiating
care discussions that overturn traditional and stereotypic gendered
expectations.
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Affiliation(s)
- Annette D Wong
- Department of Family Medicine, 4257Queen's University, Kingston, Ontario, Canada
| | - Susan P Phillips
- Department of Family Medicine, 4257Queen's University, Kingston, Ontario, Canada
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Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital – An observational study of outcome, patient characteristics and changes in DNACPR decisions. Resusc Plus 2022; 9:100209. [PMID: 35169759 PMCID: PMC8829126 DOI: 10.1016/j.resplu.2022.100209] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/23/2022] Open
Abstract
Aims The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. Methods This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. Results The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. Conclusion For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.
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12
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Fan R, Yang S, Bu X, Chen Y, Wang Y, Shen B, Qiu C, Li X. Symptomatic Features and Factors Associated With Do-Not-Resuscitate Consent in Advanced Cancer Patients Admitted to Palliative Care Ward. Am J Hosp Palliat Care 2022; 39:1312-1324. [PMID: 35041534 DOI: 10.1177/10499091211068824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aimed to conduct a retrospective cross-sectional study to investigate the prevalence of symptoms and symptom clusters on sociodemographic and disease characteristics, as well as factors associated with Do-Not-Resuscitate (DNR) consent. Advanced cancer patients were enrolled between 2018 and 2020 with available data. Demographic and clinical data were obtained for analysis from Hospital Information System (HIS) in China. Symptom clusters were extracted by hierarchical cluster analysis. Chi-square test and multiple logistic regression were conducted to investigate the prevalence characteristics of symptoms and influencing factors of DNR consent, respectively. 798 advanced cancer patients were enrolled. The most prevalent symptoms were pain (93%), anorexia (36.5%), and sleep disorders (34.2%). High heart rate was associated with poor performance status and more symptoms. Three clusters were extracted: fatigue-related, respiratory-circulatory system, and digestive system symptom clusters. The incidence of symptoms was statistically significant in age, gender, education level, residence, BMI, performance status, distress score, ADL, and primary pain level. The DNR signature rate was 15.5%. Female, distant metastasis, in-ward rescue, and appearance of dyspnea were independent influencing factors of DNR signature.Chinese hospitalized cancer patients had more symptoms burden that were influenced by various demographic characteristics, especially pain and fatigue-related symptoms. Concerning the trajectory of vital signs is important among advanced cancer patients. The DNR signature rate was lower and our finding indicating an urgency to accurately assess the prognosis and give more palliative care education to enhance DNR rates and early signing in Chinese context.
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Affiliation(s)
- Rongrong Fan
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Siyu Yang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xiaofan Bu
- 12570Xiangya Nursing School of Central South University, Changsha, China
| | - Yongyi Chen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Ying Wang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Boyong Shen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Cuiling Qiu
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xuying Li
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
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13
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Blankart CR, van Gool K, Papanicolas I, Bernal‐Delgado E, Bowden N, Estupiñán‐Romero F, Gauld R, Knight H, Abiona O, Riley K, Schoenfeld AJ, Shatrov K, Wodchis WP, Figueroa JF. International comparison of spending and utilization at the end of life for hip fracture patients. Health Serv Res 2021; 56 Suppl 3:1370-1382. [PMID: 34490633 PMCID: PMC8579204 DOI: 10.1111/1475-6773.13734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. DATA SOURCES Individual-level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). STUDY DESIGN We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age- and sex-specific effects within and across countries. In addition, we analyzed hospital-centricity, that is, the days spent in hospital and site of death. DATA COLLECTION/EXTRACTION METHODS We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. PRINCIPAL FINDINGS Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. CONCLUSIONS Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.
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Affiliation(s)
- Carl Rudolf Blankart
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- Hamburg Center for Health EconomicsUniversität HamburgHamburgGermany
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Irene Papanicolas
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of Health PolicyLondon School of EconomicsLondonUK
| | | | - Nicholas Bowden
- Department of Women's and Children's HealthUniversity of OtagoDunedinNew Zealand
| | | | - Robin Gauld
- Otago Business School and Centre for Health Systems and TechnologyUniversity of OtagoDunedinNew Zealand
| | | | - Olukorede Abiona
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Kristen Riley
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Andrew J. Schoenfeld
- Division of Orthopedic SurgeryBrigham & Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Kosta Shatrov
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
| | - Walter P. Wodchis
- Institute of Health Policy Management & EvaluationUniversity of TorontoTorontoOntarioCanada
- Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
| | - Jose F. Figueroa
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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14
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Becker C, Manzelli A, Marti A, Cam H, Beck K, Vincent A, Keller A, Bassetti S, Rikli D, Schaefert R, Tisljar K, Sutter R, Hunziker S. Association of medical futility with do-not-resuscitate (DNR) code status in hospitalised patients. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106977. [PMID: 33514639 DOI: 10.1136/medethics-2020-106977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
Guidelines recommend a 'do-not-resuscitate' (DNR) code status for inpatients in which cardiopulmonary resuscitation (CPR) attempts are considered futile because of low probability of survival with good neurological outcome. We retrospectively assessed the prevalence of DNR code status and its association with presumed CPR futility defined by the Good Outcome Following Attempted Resuscitation score and the Clinical Frailty Scale in patients hospitalised in the Divisions of Internal Medicine and Traumatology/Orthopedics at the University Hospital of Basel between September 2018 and June 2019. The definition of presumed CPR futility was met in 467 (16.2%) of 2889 patients. 866 (30.0%) patients had a DNR code status. In a regression model adjusted for age, gender, main diagnosis, nationality, language and religion, presumed CPR futility was associated with a higher likelihood of a DNR code status (37.3% vs 7.1%, adjusted OR 2.99, 95% CI 2.31 to 3.88, p<0.001). In the subgroup of patients with presumed futile CPR, 144 of 467 (30.8%) had a full code status, which was independently associated with younger age, male gender, non-Christian religion and non-Swiss citizenship. We found a significant proportion of hospitalised patients to have a full code status despite the fact that CPR had to be considered futile according to an established definition. Whether these decisions were based on patient preferences or whether there was a lack of patient involvement in decision-making needs further investigation.
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Affiliation(s)
- Christoph Becker
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
- Emergency Department, Universitatsspital Basel, Basel, Switzerland
| | - Alessandra Manzelli
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Alexander Marti
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Hasret Cam
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Katharina Beck
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Alessia Vincent
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Annalena Keller
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Daniel Rikli
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Traumatology & Orthopedics, University Hospital Basel, Basel, Switzerland
| | - Rainer Schaefert
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Kai Tisljar
- Division of Critical Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Critical Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatics, Universitatsspital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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15
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Berkowitz CM, Wolf SP, Troy J, Kamal AH. Characteristics of Advance Care Planning in Patients With Cancer Referred to Palliative Care. JCO Oncol Pract 2021; 17:e94-e100. [PMID: 33439744 DOI: 10.1200/op.20.00657] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance care planning (ACP) is a process in which patients share their values, goals, and preferences regarding future medical care. ACP can improve care quality, yet may be challenging to address for patients with cancer. We sought to characterize key components of ACP in patients with cancer as compared with patients with noncancer serious illness referred to palliative care (PC). METHODS We performed a retrospective cross-sectional analysis of initial outpatient PC visits from the Quality Data Collection Tool for PC database from 2015 to 2019. Quality Data Collection Tool is a web-based point-of-care specialty PC registry to track quality metrics. RESULTS We analyzed 1,604 patients with cancer and 1,094 patients without cancer: 44% of patients were female, 87% were White, and 98% were non-Hispanic. The average age was 72.2 years (standard deviation [SD] 15.4). Patients with cancer were on average younger than patients without cancer (66.5 [SD: 13.9] v 80.5 [SD: 13.8]) and had a higher Palliative Performance Scale (PPS) (59.5 [SD: 22.4] v 33.4 [SD: 25.1]). In our unadjusted comparison, patients with cancer were less likely to be DNR/DNI (37% v 53%; P < .0001) and less likely to have an advance directive (53% v 73%; < .0001); rates of healthcare proxy identification were similar (92.8% v 94.5%; P = .10). These differences did not persist when we accounted for age, race, sex, and PPS, with age being the primary explanatory factor. CONCLUSION Despite having serious illness meriting PC referral, many patients with cancer in our study lacked advance directives. This highlights both the important role of oncologists in facilitating ACP and the utility of PC playing a complementary role.
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Affiliation(s)
| | - Steven P Wolf
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jesse Troy
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Arif H Kamal
- Department of Medicine, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Duke University Medical Center, Durham, NC
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16
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Mody P, Pandey A, Slutsky AS, Segar MW, Kiss A, Dorian P, Parsons J, Scales DC, Rac VE, Cheskes S, Bierman AS, Abramson BL, Gray S, Fowler RA, Dainty KN, Idris AH, Morrison L. Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest. Circulation 2020; 143:641-649. [PMID: 33317326 DOI: 10.1161/circulationaha.120.050427] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. METHODS Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. RESULTS Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. CONCLUSIONS Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.
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Affiliation(s)
- Purav Mody
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas.,VA North Texas Health System, Dallas (P.M.)
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Arthur S Slutsky
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Departments of Medicine, Surgery, and Biomedical Engineering, Interdepartmental Division of Critical Care (A.S.S.), University of Toronto, Ontario, Canada
| | - Matthew W Segar
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Institute for Health Policy and Management (A.K.), University of Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine, Institute of Medical Sciences (P.D.), University of Toronto, Ontario, Canada
| | - Janet Parsons
- Applied Health Research Centre at the Li Ka Shing Knowledge Institute, St Michael's Hospital, Department of Physical Therapy and the Rehabilitation Sciences Institute (J.P.), University of Toronto, Ontario, Canada
| | - Damon C Scales
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (D.C.S.), University of Toronto, Ontario, Canada
| | - Valeria E Rac
- Ted Rogers Centre for Heart Research and Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, Toronto Health Economics and Technology Assessment (THETA) Collaborative, Institute of Health Policy, Management and Evaluation (V.E.R.), University of Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, Ontario, Canada
| | - Arlene S Bierman
- Centre for Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD (A.S.B.)
| | - Beth L Abramson
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine (B.L.A.), University of Toronto, Ontario, Canada
| | - Sara Gray
- Emergency Medicine and Critical Care, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Interdepartmental Division of Critical Care, Faculty of Medicine (S.G.), University of Toronto, Ontario, Canada
| | - Rob A Fowler
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (R.A.F.), University of Toronto, Ontario, Canada
| | - Katie N Dainty
- North York General Hospital, Institute for Health Policy and Management (K.N.D.), University of Toronto, Ontario, Canada
| | - Ahamed H Idris
- Department of Emergency Medicine (A.H.I.), University of Texas Southwestern Medical Center, Dallas
| | - Laurie Morrison
- Rescu at the Li Ka Shing Knowledge Institute, Emergency Medicine, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, Institute for Health Policy and Management (L.M.), University of Toronto, Ontario, Canada
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17
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Gott M, Morgan T, Williams L. Gender and palliative care: a call to arms. Palliat Care Soc Pract 2020; 14:2632352420957997. [PMID: 33134926 PMCID: PMC7576896 DOI: 10.1177/2632352420957997] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022] Open
Abstract
There has been a systematic and largely unconscious neglect of gender in
palliative care research, practice and policy. This is despite significant,
although previously uncollated, evidence that gender influences almost all
aspects of end-of-life preferences, experiences and care. The social situations
of women, transgender people and men often differ from one another while also
intersecting in complex ways with sex differences rooted in biology. If
palliative care is to meet its aspiration of providing universal benefit, it
urgently needs to address a range of gender inequalities currently (re)produced
at the level of the laboratory all the way through to government departments. In
this call to arms, we spotlight specific instances where gender inequalities
have been documented, for example, regarding end-of-life caregiving, end-of-life
intervention and palliative care access and benefit. We highlight how gender
inequalities intersect with other social determinants of health including
ethnicity and economic status to exacerbate situations of marginality. We
conclude by offering some practical steps that can be taken to support the
discipline to adopt a more critical gender lens to support more equitable
research, policy and practice.
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Affiliation(s)
- Merryn Gott
- Professor, School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Tessa Morgan
- Department of Public Health and Primary Care and Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Lisa Williams
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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18
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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19
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Let us talk about death: gender effects in cancer patients' preferences for end-of-life discussions. Support Care Cancer 2020; 28:4667-4675. [PMID: 31955277 PMCID: PMC7447655 DOI: 10.1007/s00520-019-05275-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/23/2019] [Indexed: 11/06/2022]
Abstract
Purpose Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients. Methods In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation. Results The importance of EOL topics differs significantly regarding issue (p = 0.002, η2 = 0.02) and gender (p < 0.001, η2 = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the “hard facts” nursing and medical care only. In contrast, females prefer to speak more about “soft facts” and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%). Conclusion The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.
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20
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Muñoz-Laboy M, Martinez O, Davison R, Fernandez I. Examining the impact of medical legal partnerships in improving outcomes on the HIV care continuum: rationale, design and methods. BMC Health Serv Res 2019; 19:849. [PMID: 31747909 PMCID: PMC6864982 DOI: 10.1186/s12913-019-4632-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/14/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Over the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams' capacity to address social and environmental threats to patients' health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV. METHODS This on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping. DISCUSSION The proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.
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Affiliation(s)
- Miguel Muñoz-Laboy
- Department of Community Health and Social Medicine, School of Medicine, City University of New York, Harris Hall, Room 313B, 160 Convent Avenue, New York, NY 10031 USA
| | - Omar Martinez
- School of Social Work, College of Public Health, Temple University, 1301 Cecil B. Moore Avenue, Ritter Annex, 10G, 5th floor, 505, Philadelphia, PA 19122 USA
| | - Robin Davison
- School of Social Work, College of Public Health, Temple University, 1301 Cecil B. Moore Avenue, Ritter Annex, 10G, 5th floor, 505, Philadelphia, PA 19122 USA
| | - Isa Fernandez
- College of Osteopathic Medicine, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, Florida, 33314 USA
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Zhao C, Dowzicky P, Colbert L, Roberts S, Kelz RR. Race, gender, and language concordance in the care of surgical patients: A systematic review. Surgery 2019; 166:785-792. [PMID: 31375322 DOI: 10.1016/j.surg.2019.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/08/2019] [Accepted: 06/11/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND No consensus exists on whether patient-provider race, gender, and language concordance provides benefits to surgical patients. We report a systematic review of the association between patient-provider concordance and patient preferences and outcomes in surgery. METHODS A systematic review of the literature was performed in Medline and PubMed using defined search terms to identify studies related to patient-provider concordance in surgical patients. We included studies with full manuscripts published in English within the United States (1998 to July 2018). RESULTS Out of 253 titles screened, 16 studies met inclusion criteria. Five studies had level 4 evidence and 11 studies had level 3 evidence. The majority of patients preferred providers with a similar background (n = 4/6). Race, gender, and language-concordance had no effect on adherence to provider recommendations (n = 3/3). No effect of race concordance on the quality of care was seen (n = 2/3). Gender concordance was associated with improved quality of care (n = 2/3). There were mixed effects of concordance on the effectiveness of communication (n = 2). CONCLUSION Few studies examine patient-provider concordance. Most patients prioritize culturally, technically, and clinically competent providers over concordance. Future research is needed regarding the influence of concordance on patient outcomes in surgery within specific patient populations and clinical settings.
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Affiliation(s)
- Cindy Zhao
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Phillip Dowzicky
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Latesha Colbert
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sanford Roberts
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA.
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22
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Perman SM, Siry BJ, Ginde AA, Grossestreuer AV, Abella BS, Daugherty SL, Havranek EP. Sex Differences in "Do Not Attempt Resuscitation" Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions. Clin Ther 2019; 41:1029-1037. [PMID: 31047712 DOI: 10.1016/j.clinthera.2019.03.017] [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] [Received: 10/13/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of "do not attempt resuscitation" (DNAR) orders and that this order would be associated with lower use of aggressive interventions. METHODS We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex. FINDINGS We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI, 1.09-1.40). No sex difference was found in procedures used after DNAR order was established. IMPLICATIONS Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Bonnie J Siry
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anne V Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stacie L Daugherty
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P Havranek
- Department of Medicine, Denver Health Medical Center, Denver, CO, USA
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Marcia L, Ashman ZW, Pillado EB, Kim DY, Plurad DS. Advance Directive and Do-Not-Resuscitate Status among Advanced Cancer Patients with Acute Care Surgical Consultation. Am Surg 2019; 84:1565-1569. [PMID: 30747670 DOI: 10.1177/000313481808401005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients (P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.
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Affiliation(s)
- Lobsang Marcia
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
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24
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Stream S, Nolan A, Kwon S, Constable C. Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center. Resuscitation 2018; 130:1-5. [PMID: 29935341 DOI: 10.1016/j.resuscitation.2018.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 06/09/2018] [Accepted: 06/18/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. OBJECTIVE To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DESIGN Retrospective chart review. SETTING/SUBJECTS Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. MEASUREMENTS Logistic regression was used to identify demographic and medical data associated with code status. RESULTS Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). CONCLUSIONS Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.
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Affiliation(s)
- Sara Stream
- New York University Internal Medicine Residency Program, NY, United States
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States; Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States
| | - Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States
| | - Catherine Constable
- Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States; Department of Medicine, New York University Langone Medical Center, NY, United States.
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25
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Shih TC, Chang HT, Lin MH, Chen CK, Chen TJ, Hwang SJ. Differences in do-not-resuscitate orders, hospice care utilization, and late referral to hospice care between cancer and non-cancer decedents in a tertiary Hospital in Taiwan between 2010 and 2015: a hospital-based observational study. BMC Palliat Care 2018; 17:18. [PMID: 29368644 PMCID: PMC5784719 DOI: 10.1186/s12904-018-0271-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/11/2018] [Indexed: 12/02/2022] Open
Abstract
Background In 2009, the Taiwanese national health insurance system substantially expanded hospice coverage for terminal cancer patients to include patients with end-stage brain, dementia, heart, lung, liver, and kidney diseases. This study aimed to evaluate differences in do-not-resuscitate (DNR) status and hospice care utilization between terminal cancer patients and advanced non-cancer patients after the policy change. Methods Data were obtained from the Death and Hospice Palliative Care Database of Taipei Veterans General Hospital in Taiwan. The differences between cancer and non-cancer patients who died in this hospital between 2010 and 2015 were analyzed in terms of patient characteristics, rates of DNR orders, hospice care utilization, number of living days after DNR order, duration of survival (DOS) after hospice care enrollment, and the rate of late referral to hospice care. Results Data for 8459 patients who died of cancer and major non-cancer terminal diseases were included. DNR order rate, hospice care utilization rate, and DOS were significantly higher for cancer patients than for non-cancer patients (p < 0.001, p < 0.001, and p < 0.001, respectively). The number of living days after DNR order and the late referral rate were significantly higher for non-cancer decedents than for cancer decedents (p < 0.001 and p < 0.001, respectively). From 2010 to 2015, there were significantly increasing trends in the hospice utilization rate, number of living days after DNR order, and rate of late referral for the cancer group (p < 0.001, p = 0.001, and p < 0.001, respectively). For the non-cancer group, there were significantly increasing trends in the rate of DNR order, hospice utilization rate, and number of living days after DNR order (p < 0.001, p < 0.001, and p = 0.029, respectively). Conclusions Further guidelines should be developed to help clinicians to promptly refer terminal cancer and non-cancer patients to hospice care. Considering the lower hospice utilization rate and the growing need for hospice care among terminal non-cancer patients, policymakers should consider how to improve the relevant levels of professional care to enhance the accessibility and availability of hospice care in Taiwan.
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Affiliation(s)
- Tzu-Chien Shih
- Department of Family Medicine, Taoyuan General Hospital, No. 1492, Zhongshan Rd., Taoyuan Dist, Taoyuan City, 330, Taiwan, Republic of China
| | - Hsiao-Ting Chang
- Department of Family Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 11217, Taiwan, Republic of China. .,School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei City, 11221, Taiwan, Republic of China.
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 11217, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei City, 11221, Taiwan, Republic of China
| | - Chun-Ku Chen
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 11217, Taiwan, Republic of China.,Institute of Clinical Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei City, 11221, Taiwan, Republic of China
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 11217, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei City, 11221, Taiwan, Republic of China
| | - Shinn-Jang Hwang
- Department of Family Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 11217, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei City, 11221, Taiwan, Republic of China
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