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Schaefer SL, Thompson CH, Gluck S, Booth AEC, Dignam CM. A Retrospective Analysis of Characteristics Favouring In-Hospital Resuscitation Plan Completion, Their Timing, and Associated Outcomes. J Clin Med 2024; 13:4098. [PMID: 39064138 PMCID: PMC11277889 DOI: 10.3390/jcm13144098] [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: 06/10/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups.
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Affiliation(s)
- Sara L. Schaefer
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Campbell H. Thompson
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Samuel Gluck
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Northern Adelaide Local Health Network, Adelaide, SA 5092, Australia
| | - Andrew E. C. Booth
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Colette M. Dignam
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
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Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, Rao K, Salins N. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024; 28:453-460. [PMID: 38738203 PMCID: PMC11080093 DOI: 10.5005/jp-journals-10071-24708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/08/2024] [Indexed: 05/14/2024] Open
Abstract
Background Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Methods Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Results Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. Conclusion The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. How to cite this article Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.
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Affiliation(s)
- Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sagar Shanmukhappa Maddani
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Souvik Chaudhuri
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Margiben T Bhatt
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shubhada Karanth
- Department of General Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anuja Damani
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krithika Rao
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Naveen Salins
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Iunius LA, Vilpert S, Meier C, Jox RJ, Borasio GD, Maurer J. Advance Care Planning: A Story of Trust Within the Family. J Appl Gerontol 2024; 43:349-362. [PMID: 37984553 PMCID: PMC10875907 DOI: 10.1177/07334648231214905] [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: 04/11/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.
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Affiliation(s)
- Lory A. Iunius
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
| | - Sarah Vilpert
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Clément Meier
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), Lausanne, Switzerland
| | - Ralf J. Jox
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics (HEC), University of Lausanne, Switzerland
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Malhotra C, Huynh VA, Shafiq M, Batcagan-Abueg APM. Advance care planning and caregiver outcomes: intervention efficacy - systematic review. BMJ Support Palliat Care 2024; 13:e537-e546. [PMID: 35788465 DOI: 10.1136/spcare-2021-003488] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
CONTEXT Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them. OBJECTIVE We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes. METHODS We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant. RESULTS Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected. CONCLUSION The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Vinh Anh Huynh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [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] [Received: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Baek AR, Hong SB, Bae S, Park HK, Kim C, Lee HK, Cho WH, Kim JH, Chang Y, Lee HB, Gil HI, Shin B, Yoo KH, Moon JY, Oh JY, Min KH, Jeon K, Baek MS. Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea. BMC Med Ethics 2023; 24:52. [PMID: 37461075 PMCID: PMC10353089 DOI: 10.1186/s12910-023-00931-y] [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: 12/23/2022] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Although the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP. METHODS This multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan-Meier curve analyses for survival were performed. RESULTS Of 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63-81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan-Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001). CONCLUSIONS After the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.
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Affiliation(s)
- Ae-Rin Baek
- Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soohyun Bae
- Department of Integrated Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Hye Kyeong Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea
| | - Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Hyun-Kyung Lee
- Department of Internal Medicine, Division of Pulmonology, Allergy and Critical Care Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jin Hyoung Kim
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Heung Bum Lee
- Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School, Jeonju, Korea
| | - Hyun-Il Gil
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Beomsu Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Young Moon
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Sejong Hospital, Sejong, Korea
| | - Jee Youn Oh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyung Hoon Min
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seong Baek
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Republic of Korea.
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Shamieh O, Alarjeh G, Qadire MA, Alrjoub W, Abu-Nasser M, Abu Farsakh F, AlHawamdeh A, Al-Omari M, Amin Z, Ayaad O, Al-Tabba A, Hui D, Bruera E, Yennurajalingam S. Decision-Making Preferences among Advanced Cancer Patients in a Palliative Setting in Jordan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20085550. [PMID: 37107832 PMCID: PMC10138437 DOI: 10.3390/ijerph20085550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/11/2023]
Abstract
Understanding patients' decision-making preferences is crucial for enhancing patients' outcomes. The current study aims to identify Jordanian advanced cancer patients' preferred decision-making and to explore the associated variables of the passive decision-making preference. We used a cross-sectional survey design. Patients with advanced cancer referred to the palliative care clinic at a tertiary cancer center were recruited. We measured patients' decision-making preferences using the Control Preference Scale. Patients' satisfaction with decision-making was assessed with the Satisfaction with Decision Scale. Cohen's kappa statistic was used to assess the agreement between decision-control preferences and actual decision-making, and the bivariate analysis with 95% CI and the univariate and multivariate logistic regression were used to examine the association and predictors of the demographical and clinical characteristics of the participants and the participants' decision-control preferences, respectively. A total of 200 patients completed the survey. The patients' median age was 49.8 years, and 115 (57.5%) were female. Of them, 81 (40.5%) preferred passive decision control, and 70 (35%) and 49 (24.5%) preferred shared and active decision control, respectively. Less educated participants, females, and Muslim patients were found to have a statistically significant association with passive decision-control preferences. Univariate logistic regression analysis showed that, being a male (p = 0.003), highly educated (p = 0.018), and a Christian (p = 0.006) were statistically significant correlates of active decision-control preferences. Meanwhile, the multivariate logistic regression analysis showed that being a male or a Christian were the only statistically significant predictors of active participants' decision-control preferences. Around 168 (84%) of participants were satisfied with the way decisions were made, 164 (82%) of patients were satisfied with the actual decisions made, and 143 (71.5%) were satisfied with the shared information. The agreement level between decision-making preferences and actual decision practices was significant (ⱪ coefficient = 0.69; 95% CI = 0.59 to 0.79). The study's results demonstrate that a passive decision-control preference was prominent among patients with advanced cancer in Jordan. Further studies are needed to evaluate decision-control preference for additional variables, such as patients' psychosocial and spiritual factors, communication, and information sharing preferences, throughout the cancer trajectory so as to inform policies and improve practice.
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Affiliation(s)
- Omar Shamieh
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
- Center for Palliative & Cancer Care in Conflict, King Hussein Cancer Center, Amman 11941, Jordan
- Faculty of Medicine, The University of Jordan, Amman 11941, Jordan
- Correspondence: ; Tel.: +962-(6)5-300-460; Fax: +962-(6)5-342-567
| | - Ghadeer Alarjeh
- Center for Palliative & Cancer Care in Conflict, King Hussein Cancer Center, Amman 11941, Jordan
| | - Mohammad Al Qadire
- Faculty of Nursing, Al al-Bayt University, Mafraq 25113, Jordan
- College of Nursing, Sultan Qaboos University, Muscat 123, Oman
| | - Waleed Alrjoub
- Center for Palliative & Cancer Care in Conflict, King Hussein Cancer Center, Amman 11941, Jordan
| | - Mahmoud Abu-Nasser
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
- Department of Medicine, King Hussein Cancer Center, Amman 11941, Jordan
| | - Fadi Abu Farsakh
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
| | | | - Mohammad Al-Omari
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
| | - Zaid Amin
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
| | - Omar Ayaad
- Office of Nursing, King Hussein Cancer Center, Amman 11941, Jordan
| | - Amal Al-Tabba
- Department of Palliative Care, King Hussein Cancer Center, Amman 11941, Jordan
| | - David Hui
- MD Anderson Cancer Center, Houston, TX 77030, USA
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Schou-Juul F, Nørgaard S, Lauridsen SMR. Ethical issues in dementia guidelines for people with dementia and informal caregivers in Denmark: A qualitative thematic synthesis. DEMENTIA 2022; 22:28-45. [PMID: 36205646 DOI: 10.1177/14713012221131856] [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: 11/16/2022]
Abstract
Numerous dementia-specific guidelines are offered to support people with dementia and their informal caregivers in dealing with dementia. However, the extent to which such guidelines address ethical issues and provide guidance for dealing with the issues has not yet been assessed. This study investigates the extent to which ethical issues are addressedin those guidelines, which ethical themes are considered and whatrecommendations are offered. We analysed Danish collected via onlinesearch engines and manual contact with relevant governmental, municipal and patient organisations from November 2020 to January 2021. To assess the scope of ethical issues in such guidelines, we devised an analytical framework using Beauchamp and Childress's four principles of biomedical ethics and a data-processing method inspired by systematic reviews. We collected a total 653 dementia guidelines and screened them using formal inclusion criteria, such as publication year, target group and public availability. The guidelines that satisfied these criteria were screened for content related to ethical issues and recommendations. The guidelines that addressed ethical issues were then coded in NVivo 12 and analysed using thematic text analysis. In total, 59 guidelines satisfied the formal inclusion criteria. Among these guidelines, 15 addressed ethical issues, which fell into four transversal themes: (1) being open about the disease, (2) accepting help, (3) the line between dignified behaviour and overstepping boundaries and (4) decision-making and autonomy. The ethical issues addressed in Danish dementia-specific guidelines were diverse. However, the addressed issues did not represent a comprehensive spectrum of ethical issues as identified in relevant literature, and only a few guidelines contained substantial ethical content. In conclusion, this study indicates that the need for guidance on ethical issues is not being met by dementia-specific guidelines and that further research is required to provide additional ethical guidance that benefits people with dementia and their informal caregivers.
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Affiliation(s)
- Frederik Schou-Juul
- National Institute of Public Health, 6174University of Southern Denmark, Copenhagen, Denmark
| | - Signe Nørgaard
- National Institute of Public Health, 6174University of Southern Denmark, Copenhagen, Denmark
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Rajendram MF, Zarisfi F, Xie F, Shahidah N, Pek PP, Yeo JW, Tan BYQ, Ma M, Do Shin S, Tanaka H, Ong MEH, Liu N, Ho AFW. External validation of the Survival After ROSC in Cardiac Arrest (SARICA) score for predicting survival after return of spontaneous circulation using multinational pan-asian cohorts. Front Med (Lausanne) 2022; 9:930226. [PMID: 36160129 PMCID: PMC9492983 DOI: 10.3389/fmed.2022.930226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/12/2022] [Indexed: 12/03/2022] Open
Abstract
Aim Accurate and timely prognostication of patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC) is crucial in clinical decision-making, resource allocation, and communication with family. A clinical decision tool, Survival After ROSC in Cardiac Arrest (SARICA), was recently developed, showing excellent performance on internal validation. We aimed to externally validate SARICA in multinational cohorts within the Pan-Asian Resuscitation Outcomes Study. Materials and methods This was an international, retrospective cohort study of patients who attained ROSC after OHCA in the Asia Pacific between January 2009 and August 2018. Pediatric (age <18 years) and traumatic arrests were excluded. The SARICA score was calculated for each patient. The primary outcome was survival. We used receiver operating characteristics (ROC) analysis to calculate the model performance of the SARICA score in predicting survival. A calibration belt plot was used to assess calibration. Results Out of 207,450 cases of OHCA, 24,897 cases from Taiwan, Japan and South Korea were eligible for inclusion. Of this validation cohort, 30.4% survived. The median SARICA score was 4. Area under the ROC curve (AUC) was 0.759 (95% confidence interval, CI 0.753–0.766) for the total population. A higher AUC was observed in subgroups that received bystander CPR (AUC 0.791, 95% CI 0.782–0.801) and of presumed cardiac etiology (AUC 0.790, 95% CI 0.782–0.797). The model was well-calibrated. Conclusion This external validation study of SARICA demonstrated high model performance in a multinational Pan-Asian cohort. Further modification and validation in other populations can be performed to assess its readiness for clinical translation.
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Affiliation(s)
| | - Faraz Zarisfi
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Feng Xie
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Pin Pin Pek
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Matthew Ma
- Department of Emergency Medicine, National Taiwan University Hospital, National Taiwan University, Taipei City, Taiwan
| | - Sang Do Shin
- Department of Emergency Medicine, School of Medicine, Seoul National University, Seoul, South Korea
| | - Hideharu Tanaka
- Department of Emergency Medical System, Graduate School of Kokushikan University, Tokyo, Japan
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
- SingHealth AI Health Program, Singapore Health Services, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
- *Correspondence: Andrew Fu Wah Ho,
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10
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Tolle SW, Hedberg K. Effectiveness of Advance Care Planning: What Works, What Doesn’t, and What Needs to Change? THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022333210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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11
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Gautier WC, Abaye M, Dev S, Seaman JB, Butler RA, Norman MK, Arnold RM, Witteman HO, Cook TE, Mohan D, White DB. An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness. Am J Crit Care 2022; 31:189-201. [PMID: 35466353 DOI: 10.4037/ajcc2022105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support. OBJECTIVE To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness. METHODS A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively. RESULTS Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training. CONCLUSIONS Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.
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Affiliation(s)
- William C. Gautier
- William C. Gautier is a medical student, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Menna Abaye
- Menna Abaye is a research project manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Shelly Dev
- Shelly Dev is an assistant professor, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor, School of Nursing, Department of Acute and Tertiary Care, University of Pittsburgh, Pennsylvania
| | - Rachel A. Butler
- Rachel A. Butler is a research program manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Marie K. Norman
- Marie K. Norman is an associate professor, School of Medicine, General Internal Medicine, Medicine and Clinical and Translational Science, Innovation Design for Education and Assessment (IDEA) Lab, University of Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Robert M. Arnold is a professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, and University of Pittsburgh Medical Center Palliative and Supportive Institute, Pennsylvania
| | - Holly O. Witteman
- Holly O. Witteman is a professor, Department of Family and Emergency Medicine & Office of Education and Professional Development, Faculty of Medicine, Laval University, Québec, Canada
| | - Tara E. Cook
- Tara E. Cook was an assistant professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pennsylvania
| | - Deepika Mohan
- Deepika Mohan is an associate professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
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12
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Tsai WT, Chen CM, Chung MC, Tsai PY, Liu YT, Tang FC, Lin YL. Important Factors Influencing Willingness to Participate in Advance Care Planning among Outpatients: A Pilot Study in Central Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5266. [PMID: 35564659 PMCID: PMC9101214 DOI: 10.3390/ijerph19095266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/17/2022]
Abstract
Advance care planning (ACP) and advance directives (ADs) ensure patient autonomy in end-of life care. The number of ADs made and followed in Taiwan is still lacking. This study aimed to determine the factors that influence the willingness to participate in ACP among outpatients in Taiwan. In this study, we conducted a cross-sectional survey based on convenient sampling methods. The questionnaire included questions about participants' basic sociodemographic information, knowledge of ACP, and awareness of ACP. A total of 198 adults who were outpatients of a family medicine clinic in an affiliated hospital in Taiwan were recruited. The associations between each variable were evaluated using the χ2 test. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the logistic regression method to examine the influence of each variable on willingness to participate in ACP. Being happy and being a healthcare professional were positively correlated with ACP participation. A lack of ACP knowledge (OR = 0.30 in model A and OR = 0.42 in model C), valuing "Reducing families' end-of-life decision-making burden" (OR = 2.53 in model B and OR = 2.65 in model C), and a "Belief in a good death" (OR = 4.02 in model B and OR = 4.10 in Model C) were the main factors affecting subjects' willingness to participate in ACP. Knowing which factors influence willingness to participate in ACP helps in the promotion of ACP. Continuously educating both the general public and healthcare professionals strengthens knowledge about the right to autonomy, about its associated laws, and about the ACP process, and thus, programs should be created to provide this education. Additionally, taking into account the differences between cultures can be helpful.
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Affiliation(s)
- Wan-Ting Tsai
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Chun-Min Chen
- Big Data Center, Changhua Christian Hospital, Changhua 500, Taiwan;
| | - Ming-Cheng Chung
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Pei-Yu Tsai
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
| | - Yen-Tzu Liu
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
- Big Data Center, Changhua Christian Hospital, Changhua 500, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Holistic Wellness, Mingdao University, Changhua 500, Taiwan
- Post Baccalaureate Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Feng-Cheng Tang
- Department of Occupational Medicine, Changhua Christian Hospital, Changhua 500, Taiwan;
- Department of Leisure Services Management, Chaoyang University of Technology, Taichung 413, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ying-Li Lin
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (W.-T.T.); (M.-C.C.); (P.-Y.T.); (Y.-T.L.)
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13
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Wong ELY, Lau JYC, Chau PYK, Chung RYN, Wong SYS, Woo J, Yeoh EK. Caregivers’ Experience of End-of-Life Stage Elderly Patients: Longitudinal Qualitative Interview. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042101. [PMID: 35206288 PMCID: PMC8871572 DOI: 10.3390/ijerph19042101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/01/2023]
Abstract
Objectives: This study seeks to provide an understanding of the changing experiences in caregivers of end-of-life patients in Hong Kong through exploring their caregiving journey. Methods: Using longitudinal individual qualitative interviews, a total of 14 caregivers of community-dwelling elderly patients receiving end-of-life care were recruited between 2015 and 2016. A series of in-depth interviews and observations were conducted in 14 cases during the end-of-life journey. Results: A thematic analysis revealed four sequential experiential stages, abbreviated as “CAPE” that caregivers confronted: Stage 1 Certainty, (1a) lack of certainty regarding the progression of decline at the end-stage of life (1b) feelings of despair as patients’ function decreased; Stage 2 Ambivalence, (2a) feelings of ambivalence after decisions were made regarding EOL care, (2b) struggle over care responsibility within families; Stage 3 Perturbed, (3a) varied in quality of EOL care, (3b) depressed mood arisen from frequent exposure to the suffering of elderly patients; and Stage 4 Expectation, (4a) losing the caregiving role as patients showing signs of imminent death. Conclusions: These findings increase our understanding of caregivers’ in-depth experience over time that arise within the structural context of end-of-life care. Our data highlights the need for end of life related knowledge and information, provision of a caring atmosphere and communication, and professional-led detachment in creating caregiving-friendly service in healthcare system, thus as to provide support and alleviate stress for caregivers with their critical responsibility and role during the course of end-of-life care.
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Affiliation(s)
- Eliza Lai-Yi Wong
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
- Correspondence:
| | - Janice Ying-Chui Lau
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
| | - Patsy Yuen-Kwan Chau
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
| | - Roger Yat-Nork Chung
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
| | - Samuel Yeung-Shan Wong
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
| | - Jean Woo
- The Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China;
| | - Eng-Kiong Yeoh
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; (J.Y.-C.L.); (P.Y.-K.C.); (R.Y.-N.C.); (S.Y.-S.W.); (E.-K.Y.)
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14
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Diegelmann S, Bidmon S, Terlutter R. Promoting advance care planning via mediated health resources: A systematic mixed studies review. PATIENT EDUCATION AND COUNSELING 2022; 105:15-29. [PMID: 34144856 DOI: 10.1016/j.pec.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This systematic review aims (a) to analyze the message design of mediated advance care planning (ACP) interventions targeted at adults from a social marketing and health communication perspective, (b) to identify associations between message design and ACP outcomes, and (c) to illuminate gaps in the literature and highlight needs for future research. METHODS A systematic mixed studies review was conducted. Empirical articles on mediated ACP interventions were systematically searched by using nine scientific databases with keywords related to ACP and mediated health communication. Data were synthesized using a sequential explanatory approach. RESULTS A total of 11,824 titles were identified, of which 36 studies were included. Interventions disseminated ACP messages via video (36%), digital channels (22%), print (19%), a combination of channels (19%), and mass media (3%). The interventions used generic (42%), targeted (33%), and tailored (25%) communication. Overall, the evidence suggests that mediated ACP resources positively impact ACP Process and Action outcomes. CONCLUSION This study has shown that mediated ACP interventions use various contents, formats, and structures to influence patient-centered ACP outcomes. Most message design techniques were associated with positive ACP outcomes. PRACTICE IMPLICATIONS Mediated ACP resources are a promising approach to encourage ACP among adults.
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Affiliation(s)
- Svenja Diegelmann
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria.
| | - Sonja Bidmon
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
| | - Ralf Terlutter
- Alpen-Adria-Universität Klagenfurt, Department of Marketing and International Management, Universitätsstrasse 65-67, 9020 Klagenfurt, Austria
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15
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Carhuapoma LR, Thayer WM, Elmore CE, Gildersleeve J, Singh T, Shaukat F, Uveges MK, Gray T, Chu C, Song D, Hollen PJ, Wenzel J, Jones RA. Employing a mobile health decision aid to improve decision-making for patients with advanced prostate cancer and their decision partners/proxies: the CHAMPION randomized controlled trial study design. Trials 2021; 22:631. [PMID: 34530868 PMCID: PMC8444368 DOI: 10.1186/s13063-021-05602-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/04/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Metastatic prostate cancer remains a lethal malignancy that warrants novel supportive interventions for patients and their decision partners and proxies. Decision aids have been applied primarily to patients with localized disease, with minimal inclusion of patients with advanced prostate cancer and their decision partners. The use of a community patient navigator (CPN) has been shown to have a positive supportive role in health care, particularly with individuals from minority populations. Research is needed to evaluate decision support interventions tailored to the needs of advanced prostate cancer patients and their decision partners in diverse populations. METHODS Guided by Janis and Mann's Conflict Model of Decision Making, the Cancer Health Aid to Manage Preferences and Improve Outcomes through Navigation (CHAMPION) is a randomized controlled trial to assess the feasibility and acceptability of a mobile health (mHealth), CPN-administered decision support intervention designed to facilitate communication between patients, their decision partners, and the healthcare team. Adult prostate cancer patients and their decision partners at three mid-Atlantic hospitals in the USA were randomized to receive enhanced usual care or the decision intervention. The CHAMPION intervention includes a theory-based decision-making process tutorial, immediate and health-related quality of life graphical summaries over time (using mHealth), values clarification via a balance sheet procedure with the CPN support during difficult decisions, and facilitated discussions with providers to enhance informed, shared decision-making. DISCUSSION The CHAMPION intervention is designed to leverage dynamic resources, such as CPN teams, mHealth technology, and theory-based information, to support decision-making for advanced prostate cancer patients and their decision partners. This intervention is intended to engage decision partners in addition to patients and represents a novel, sustainable, and scalable way to build on individual and community strengths. Patients from minority populations, in particular, may face unique challenges during clinical communication. CHAMPION emphasizes the inclusion of decision partners and CPNs as facilitators to help address these barriers to care. Thus, the CHAMPION intervention has the potential to positively impact patient and decision partner well-being by reducing decisional conflict and decision regret related to complex, treatment-based decisions, and to reduce cancer health disparities. Trial registration ClinicalTrials.gov NCT03327103 . Registered on 31 October 2017-retrospectively registered. World Health Organization Trial Registration Data Set included in Supplementary Materials.
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Affiliation(s)
- Lourdes R. Carhuapoma
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
- Division of Neurosciences Critical Care, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Winter M. Thayer
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland 21205 USA
| | - Catherine E. Elmore
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
| | - Jane Gildersleeve
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
| | - Tanmay Singh
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 401 North Broadway, Baltimore, MD 21231 USA
| | - Farah Shaukat
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland 21205 USA
| | - Melissa K. Uveges
- Boston College Connell School of Nursing, Maloney Hall 375, 140 Commonwealth Avenue, Chestnut Hill, MA USA
| | - Tamryn Gray
- Palliative Care, Dana Farber Cancer Institute, 375 Longwood Avenue, Boston, MA 02215 USA
| | - Crystal Chu
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
| | - Daniel Song
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 401 North Broadway, Baltimore, MD 21231 USA
| | - Patricia J. Hollen
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
| | - Jennifer Wenzel
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland 21205 USA
| | - Randy A. Jones
- University of Virginia School of Nursing, 202 Jeanette Lancaster Way, PO Box 800782, Charlottesville, VA 22908 USA
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16
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Nickels BM, Tenzek KE, Lattimer TA. This Is Us: An Analysis of Mediated Family Communication at End-of-Life. OMEGA-JOURNAL OF DEATH AND DYING 2021:302228211036307. [PMID: 34338068 DOI: 10.1177/00302228211036307] [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: 11/17/2022]
Abstract
Death is a ubiquitous theme in television dramas and we argued that mediated depictions of end-of-life experiences have the potential to provide glimpses into the ways in which characters experience real-life issues and can serve as conversation starters within family viewers. The study aimed to identify how a popular television drama, This is Us, depicted end-of-life communication. Analysis of season one revealed 54 conversations about end-of-life, two explicit death scenes, and three implied death scenes. Results also illustrate how the storyline within the show clearly depicts the impact end-of-life has on the family system, emphasizing the ongoing interdependence, hierarchy, and boundary (re)negotiation as a result of death. Findings advance understanding of how mediated narratives can illustrate end-of-life scenarios and conversations within the family system and can provide observational opportunities for modeling end-of-life communication behaviors within their families.
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Affiliation(s)
- Bonnie M Nickels
- School of Communication, 6925Rochester Institute of Technology, Rochester Institute of Technology, New York, United States
| | - Kelly E Tenzek
- Department of Communication, 12292University at Buffalo, University at Buffalo, State University of New York, New York, United States
| | - Tahleen A Lattimer
- Department of Communication, 12292University at Buffalo, University at Buffalo, State University of New York, New York, United States
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17
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Zigdon A, Nissanholtz-Gannot R. Barriers in implementing the dying patient law: the Israeli experience - a qualitative study. BMC Med Ethics 2020; 21:126. [PMID: 33308218 PMCID: PMC7731544 DOI: 10.1186/s12910-020-00564-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Coping with end-of-life issues is a major challenge for governments and health systems. Despite progress in legislation, many barriers exist to its full implementation. This study is aimed at identifying these end-of-life barriers in relation to Israel. Methods Qualitative in-depth interviews using professionals and decision makers in the health-care and related systems (n = 37) were carried out, along with two focus groups based on brainstorming techniques consisting of nurses (n = 10) and social workers (n = 10). Data was managed and analyzed using Naralyzer software. Results Qualitative analysis showed identification of six primary barriers: 1) law, procedures, and forms; 2) clinical aspects; 3) human aspects; 4) knowledge and skills of medical teams; 5) communication; and 6) resource allocation. These were further divided into 44 sub area barriers. Conclusions This study highlights the role of the family doctor in end-of-life by training physicians in decision-making workshops and increasing their knowledge in the field of palliative medicine. Effectively channeling resources, knowledge, and support for medical teams, by accounting for the structure and response of the units for home treatment will improve patient’s access to information on and support for end-of-life laws, as well as reduce legislative barriers in other countries that face the same issues.
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Affiliation(s)
- Avi Zigdon
- Department of Health Systems Management, School of Health Sciences, Ariel University, Science Park, P.O.B. 3, 4070000, Ariel, Israel.
| | - Rachel Nissanholtz-Gannot
- Department of Health Systems Management, School of Health Sciences, Ariel University, Science Park, P.O.B. 3, 4070000, Ariel, Israel.,Smokler Center of Health Policy Research, Myers-JDC-Brookdale Institute, P.O.B. 3886, 91037, Jerusalem, Israel
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18
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Kubi B, Istl AC, Lee KT, Conca-Cheng A, Johnston FM. Advance Care Planning in Cancer: Patient Preferences for Personnel and Timing. JCO Oncol Pract 2020; 16:e875-e883. [DOI: 10.1200/jop.19.00367] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE: Opportunities for advance care planning (ACP) discussions continue to be missed despite the demonstrated benefit of such conversations. This is in part because of a poor understanding of patient preferences. We aimed to determine oncology patients’ preferences surrounding ACP with a focus on the choice of which health care providers to have the conversation with and the timing of conversations. METHODS: A cross-sectional 19-question survey of surgical and medical oncology patients in a tertiary care hospital was conducted that assessed knowledge, experience, and preferences surrounding ACP. Quantitative variables were reported with descriptive statistics, and a coding structure was developed to analyze qualitative data. RESULTS: Two hundred patients were surveyed. Only 24% of patients reported previously having ACP discussions with their physicians despite 82.5% reporting a wish to do so. Patients felt that these discussions were a priority for them (to alleviate familial guilt, maintain control, and prevent others’ values from guiding end-of-life care), but they reported that previous experiences with ACP had been neither comprehensive nor effective. Most patients (43.5%) preferred to have ACP discussions with their primary care providers (PCPs) compared with 7% preferring their surgeon and 5.5% preferring their oncologist. Trust and familiarity with PCPs arose as the dominant theme underlying this selection. Most patients (94%) preferred to have ACP discussions early, with 45% wishing such a discussion had been initiated before their cancer diagnosis. CONCLUSION: Patients with cancer prefer to have ACP discussions with their PCPs and prefer to do so early in their disease course.
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Affiliation(s)
- Boateng Kubi
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Kimberley T. Lee
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Sutter R, Meyer-Zehnder B, Baumann SM, Marsch S, Pargger H. Advance Directives in the Neurocritically Ill: A Systematic Review. Crit Care Med 2020; 48:1188-1195. [PMID: 32697490 DOI: 10.1097/ccm.0000000000004388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the frequency of advance directives or directives disclosed by healthcare agents and their influence on decisions to withdraw/withhold life-sustaining care in neurocritically ill adults. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify studies describing directives of neurocritically ill patients from 2000 to 2019. The review was registered prior to the screening process (International Prospective Register of Systematic Reviews identification number 149185). DATA EXTRACTION Data were collected using standardized forms. Primary outcomes were the frequency of directives and associated withholding/withdrawal of life-sustaining care. DATA SYNTHESIS Out of 721 articles, 25 studies were included representing 35,717 patients. The number of studies and cohort sizes increased over time. A median of 39% (interquartile range, 14-72%) of patients had directives and/or healthcare agents. The presence of directives was described in patients with stroke, status epilepticus, neurodegenerative disorders, neurotrauma, and neoplasms, with stroke patients representing the largest subgroup. Directives were more frequent among patients with neurodegenerative disorders compared with patients with other illnesses (p = 0.043). In reference to directives, care was adapted in 71% of European, 50% of Asian, and 42% of American studies, and was withheld or withdrawn more frequently over time with a median of 58% (interquartile range, 39-89%). Physicians withheld resuscitation in reference to directives in a median of 24% (interquartile range, 22-70%). CONCLUSIONS Studies regarding the use and translation of directives in neurocritically ill patients are increasing. In reference to directives, care was adapted in up to 71%, withheld or withdrawn in 58%, and resuscitation was withheld in every fourth patient, but the quality of evidence regarding their effects on critical care remains weak and the risk of bias high. The limited number of patients having directives is worrisome and studies aiming to increase the use and translation of directives are scarce. Efforts need to be made to increase the perception, use, and translation of directives of the neurocritically ill.
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Affiliation(s)
- Raoul Sutter
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | | | | | - Stephan Marsch
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Visvanathan A, Mead GE, Dennis M, Whiteley WN, Doubal FN, Lawton J. The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. BMC Med Inform Decis Mak 2020; 20:98. [PMID: 32487145 PMCID: PMC7268726 DOI: 10.1186/s12911-020-01137-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 12/01/2022] Open
Abstract
Background Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. Method Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. Results Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. Conclusion The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.
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Affiliation(s)
- A Visvanathan
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK.
| | - G E Mead
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - M Dennis
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - W N Whiteley
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - F N Doubal
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - J Lawton
- Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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Lincoln T, Shields AM, Buddadhumaruk P, Chang CCH, Pike F, Chen H, Brown E, Kozar V, Pidro C, Kahn JM, Darby JM, Martin S, Angus DC, Arnold RM, White DB. Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs. BMJ Open 2020; 10:e033521. [PMID: 32229520 PMCID: PMC7170558 DOI: 10.1136/bmjopen-2019-033521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution. METHODS AND ANALYSIS This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants. ETHICS AND DISSEMINATION We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02445937.
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Affiliation(s)
- Taylor Lincoln
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anne-Marie Shields
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Praewpannarai Buddadhumaruk
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis Pike
- Department of Neuroscience, Ely Lilly and Company, Indianapolis, Indiana, USA
| | - Hsiangyu Chen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elke Brown
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Veronica Kozar
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Caroline Pidro
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Susan Martin
- Donald Wolff Center for Quality Improvement and Innovation, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Palliative Support Institute, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
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Walter JK, Hill DL, DiDomenico C, Parikh S, Feudtner C. A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review. BMC Palliat Care 2019; 18:116. [PMID: 31864331 PMCID: PMC6925857 DOI: 10.1186/s12904-019-0504-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents. DISCUSSION Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility. CONCLUSIONS Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.
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Affiliation(s)
- Jennifer K. Walter
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Douglas L. Hill
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Concetta DiDomenico
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Shefali Parikh
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
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Richards CA, Hebert PL, Liu CF, Ersek M, Wachterman MW, Taylor LL, Reinke LF, O’Hare AM. Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services. JAMA Netw Open 2019; 2:e1913115. [PMID: 31603487 PMCID: PMC6804019 DOI: 10.1001/jamanetworkopen.2019.13115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022] Open
Abstract
Importance Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care. Objectives To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death. Design, Setting, and Participants This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019. Exposure Cessation of dialysis treatment before death. Main Outcomes and Measures Bereaved Family Survey ratings. Results Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001). Conclusions and Relevance This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Paul L. Hebert
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Chuan-Fen Liu
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center–Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Melissa W. Wachterman
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie L. Taylor
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
| | - Lynn F. Reinke
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- School of Nursing, Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Ann M. O’Hare
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- University of Washington School of Medicine, Seattle
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Content analysis of Advance Directives completed by patients with advanced cancer as part of an Advance Care Planning intervention: insights gained from the ACTION trial. Support Care Cancer 2019; 28:1513-1522. [PMID: 31278462 PMCID: PMC6989617 DOI: 10.1007/s00520-019-04956-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Writing an Advance Directive (AD) is often seen as a part of Advance Care Planning (ACP). ADs may include specific preferences regarding future care and treatment and information that provides a context for healthcare professionals and relatives in case they have to make decisions for the patient. The aim of this study was to get insight into the content of ADs as completed by patients with advanced cancer who participated in ACP conversations. METHODS A mixed methods study involving content analysis and descriptive statistics was used to describe the content of completed My Preferences forms, an AD used in the intervention arm of the ACTION trial, testing the effectiveness of the ACTION Respecting Choices ACP intervention. RESULTS In total, 33% of 442 patients who received the ACTION RC ACP intervention completed a My Preferences form. Document completion varied per country: 10.4% (United Kingdom), 20.6% (Denmark), 29.2% (Belgium), 41.7% (the Netherlands), 61.3% (Italy) and 63.9% (Slovenia). Content analysis showed that 'maintaining normal life' and 'experiencing meaningful relationships' were important for patients to live well. Fears and worries mainly concerned disease progression, pain or becoming dependent. Patients hoped for prolongation of life and to be looked after by healthcare professionals. Most patients preferred to be resuscitated and 44% of the patients expressed maximizing comfort as their goal of future care. Most patients preferred 'home' as final place of care. CONCLUSIONS My Preferences forms provide some insights into patients' perspectives and preferences. However, understanding the reasoning behind preferences requires conversations with patients.
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25
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Aslakson RA, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Moore M, Bhamidipati A, Mora S, Miller J, Singh S, Swoboda SM, Pawlik TM, Weiss M, Volandes A, Smith TJ, Bridges JFP, Roter DL. Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial. J Palliat Med 2019; 22:764-772. [PMID: 30964385 DOI: 10.1089/jpm.2018.0209] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Palliative Care Section, Department of Medicine, Stanford University School of Medicine, Stanford, California.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarina R Isenberg
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,4 Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Norah L Crossnohere
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison M Conca-Cheng
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Madeleine Moore
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Akshay Bhamidipati
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silvia Mora
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judith Miller
- 6 Patient/Family Member Co-Investigator, Ellicott City, Maryland
| | - Sarabdeep Singh
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra M Swoboda
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Weiss
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Angelo Volandes
- 9 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J Smith
- 10 Department of Oncology and Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - John F P Bridges
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Debra L Roter
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Higel T, Alaoui A, Bouton C, Fournier JP. Effect of Living Wills on End-of-Life Care: A Systematic Review. J Am Geriatr Soc 2018; 67:164-171. [PMID: 30508301 DOI: 10.1111/jgs.15630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To comprehensively assess the effect of a living will on end-of-life care. DESIGN Systematic review with narrative analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. PARTICIPANTS All interventional and observational studies were included, excepting those with fictive cases. Included studies were conducted in adults with and without living wills, excluding individuals with specific psychiatric living wills. MEASUREMENTS Two authors independently extracted study and participant characteristics and outcomes related to end-of-life care (place of death, hospitalization and intensive care unit management, life-sustaining treatments, restricted care). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. RESULTS From 7,596 records identified, 28 observational studies were included, 19 conducted in the United States, 7 in Europe, and 1 each in Canada and Australia. Place of death was assessed in 14 studies, life-sustaining treatments in 13, decision for restricted care in 12, and hospitalization in 8. Risk of bias was serious for 26 studies and moderate for 2. Twenty-one studies reported significantly less medical management for individuals with a living will, 3 reported more medical management, and the difference was not significant in 37. CONCLUSION Methodological quality of included studies was insufficient to offer reliable results. The effect of living wills appears limited in view of the importance and direction of potential biases. Further studies including larger populations, considering main confounding factors, and documenting the real presence of a living will in medical records are necessary to reach stronger conclusions on the effect of living wills on end-of-life care. J Am Geriatr Soc 67:164-171, 2019.
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Affiliation(s)
- Thomas Higel
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France
| | - Anna Alaoui
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France
| | - Céline Bouton
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France
| | - Jean-Pascal Fournier
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France
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Bravo G, Sene M, Arcand M, Hérault É. Effects of advance care planning on confidence in surrogates' ability to make healthcare decisions consistent with older adults' wishes: Findings from a randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2018; 101:1256-1261. [PMID: 29452728 DOI: 10.1016/j.pec.2018.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 01/08/2018] [Accepted: 02/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate how confidence in surrogates' ability to make consistent decisions in the future change over time, in the context of an ACP intervention that did not improve surrogates' ability to predict an older adult's hypothetical treatment preferences. METHODS The study involved 235 older adults and surrogates, randomly allocated to an ACP or control intervention. At baseline, end of intervention, and six months later, participants were asked how confident they were in the surrogate making decisions in the future that would match the older adult's wishes. RESULTS By the end of the intervention, confidence had increased among older adults and surrogates involved in ACP (OR = 3.1 and 5.8 respectively, p < 0.001), while less change occurred among controls. Over the following six months, confidence remained stable among older adults but decreased among surrogates (OR = 0.5, p = 0.005). CONCLUSION ACP increases confidence in surrogates' ability to make consistent decisions, which may lighten the burden of substitute decision making. Efforts to improve substitute decision-making must continue so that participants' confidence is not based on the mistaken assumption that surrogates can make consistent decisions. PRACTICE IMPLICATIONS Professionals involved in ACP should inform participants that confidence in the surrogate may increase in the absence of enhanced predictive ability.
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada.
| | - Modou Sene
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada; Department of Family Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Élodie Hérault
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
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Dennis MK, Washington KT. "Just Let Me Go": End-of-Life Planning Among Ojibwe Elders. THE GERONTOLOGIST 2018; 58:300-307. [PMID: 27927735 PMCID: PMC5946829 DOI: 10.1093/geront/gnw151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/19/2016] [Indexed: 11/14/2022] Open
Abstract
Purpose of the Study Although advance care planning (ACP) is designed to promote person-centered end-of-life care, the principles underpinning it are at odds with the values and norms of many American Indian/Alaska Native (AI/AN) communities, contributing to low rates of ACP among AI/AN elders. The purpose of this study was to explore the apparent tension between Western approaches to end-of-life care, including its emphasis on ACP, and the expectations and wishes of one community of AI elders, in hopes of informing more culturally appropriate approaches to planning for end-of-life care. Design and Methods About 20 tribal elders living on a Great Lakes reservation participated in semistructured, face-to-face interviews. Participants were recruited through convenience and snowball sampling techniques. The interviews were analyzed using an inductive thematic analysis approach. Results Despite seeing little need for ACP, the elders were generally open to discussing the care they would want at end of life. Many were readily able to describe their wishes for a peaceful death and had already developed funeral and burial or cremation plans. Although establishing one's individual legacy was not a salient end-of-life concern for the elders, several found meaning in describing their contributions to preserving their families, the community, and their cultural lifeways. Implications A lack of formal ACP within AI/AN communities does not necessarily reflect a cultural aversion to discussing preferences for end of life. Efforts to increase ACP in tribal communities would likely be enhanced by acknowledgment of the spiritual and cultural significance of death and dying for many AI/AN individuals.
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Affiliation(s)
| | - Karla T Washington
- Department of Family and Community Medicine, University of Missouri, Columbia
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29
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Green MJ, Van Scoy LJ, Foy AJ, Stewart RR, Sampath R, Schubart JR, Lehman EB, Dimmock AEF, Bucher AM, Lehmann LS, Harlow AF, Yang C, Levi BH. A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making. Am J Hosp Palliat Care 2017; 35:866-874. [PMID: 29186982 DOI: 10.1177/1049909117744554] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.
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Affiliation(s)
- Michael J Green
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Lauren J Van Scoy
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Renee R Stewart
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Ramya Sampath
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane R Schubart
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.,6 Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Anne E F Dimmock
- 2 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Ashley M Bucher
- 4 Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa S Lehmann
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,7 National Center for Ethics in Health Care, Veterans Administration, Washington, DC, USA
| | - Alyssa F Harlow
- 5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Chengwu Yang
- 8 Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY, USA
| | - Benjamin H Levi
- 1 Department of Humanities, Penn State College of Medicine, Hershey, PA, USA.,9 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Yasui H, Iwase S, Ariyoshi K, Nojima M, Yoshiuchi K. Decline of Physical Activity in Terminally Ill Patients Could Be Useful for Predicting Short-Term Survival. Am J Hosp Palliat Care 2017; 35:749-753. [PMID: 29145731 DOI: 10.1177/1049909117741472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Although it is recommended that all terminally ill patients receive advance care planning (ACP), this is occasionally challenging because of the difficulty in predicting survival. There are some indexes for predicting survival, but few are accurate, especially at the terminal stages of illness. METHODS Twenty-two patients at the terminal stages of cancer were retrospectively analyzed. We assessed their physical activity and condition using activities of daily living (ADL) scores for 1 month before the death. The ADL scores included 7 items: walking, bathing, grooming, dressing, eating, transferring, and toileting. RESULTS Survival time after the first decline of physical activity was calculated (median: 13 days, 95% confidence interval [95% CI]: 5.6-20.4 days). Survival time after the second (median: 5 days, 95% CI: 0-10.9 days), third (median: 5 days, 95% CI: 0-13.4 days), and fourth (median time: 1 day, 95% CI: not applicable due to small size) decline of physical activity was also calculated. CONCLUSION Change in physical activity seems helpful for estimating survival time, especially at the end of life, and this index could be useful for coordinating final ACP.
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Affiliation(s)
- Hiroki Yasui
- 1 Department of Psychosomatic Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoru Iwase
- 2 Department of General Internal Medicine, Saitama Medical University, Saitama, Japan
| | - Keisuke Ariyoshi
- 3 NPO JORTC (Japanese Organization for Research and Treatment of Cancer), Tokyo, Japan
| | - Masanori Nojima
- 4 Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- 5 Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Abstract
The palliative care approach for survivors begins with comprehensive assessment of communication and advance care planning needs and the physical, psychological and psychiatric, social, spiritual and religious, and cultural domains. Communication and decision-making about difficult issues should include responding to emotions, planning for future communication needs, and considering reasons for miscommunication. Key palliative approaches to symptom management include addressing physical and psychosocial concerns, and using nonpharmacologic approaches first or together with medications. Physicians should address advance care planning in older cancer survivors and those at significant risk of recurrence and mortality, ideally through ongoing conversations in a longitudinal care relationship.
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Affiliation(s)
- Sydney M Dy
- Primary Care for Cancer Survivors Program, Department of Medicine, Johns Hopkins University, Room 609, 624 North Broadway, Baltimore, MD 21209, USA.
| | - Sarina R Isenberg
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Room 609, 624 North Broadway, Baltimore, MD 21209, USA
| | - Nebras Abu Al Hamayel
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Room 609, 624 North Broadway, Baltimore, MD 21209, USA
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Pecanac KE. Communicating Delicately: Introducing the Need to Make a Decision About the Use of Life-Sustaining Treatment. HEALTH COMMUNICATION 2017; 32:1261-1271. [PMID: 27669102 DOI: 10.1080/10410236.2016.1217455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this study was to explore how clinicians introduce the need to make a decision about the use of life-sustaining treatment and how surrogates respond to these introductions during family conferences in the intensive care unit. This article focuses on the use of the perspective-display sequence as a way to introduce the decision-making conversation. In the family conferences, the perspective-display sequence involved (a) the clinician's perspective-display invitation of the surrogates' assessment of the patient's wishes, (b) the surrogates' reply or assessment, and (c) the clinician's decision proposal, which often incorporates the surrogates' assessment. Asking about the patient's wishes is a delicate way to ease into the decision-making conversation. By using the perspective-display sequence, clinicians are also participating in shared decision making; their decision proposal is co-constructed with surrogates' understanding of the patient's wishes regarding the treatment.
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Sulmasy DP, Hughes MT, Yenokyan G, Kub J, Terry PB, Astrow AB, Johnson JA, Ho G, Nolan MT. The Trial of Ascertaining Individual Preferences for Loved Ones' Role in End-of-Life Decisions (TAILORED) Study: A Randomized Controlled Trial to Improve Surrogate Decision Making. J Pain Symptom Manage 2017; 54:455-465. [PMID: 28712987 PMCID: PMC5632104 DOI: 10.1016/j.jpainsymman.2017.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/02/2017] [Accepted: 07/06/2017] [Indexed: 11/23/2022]
Abstract
CONTEXT Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role. OBJECTIVES To test the effectiveness of an intervention to help surrogate decision makers. METHODS One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention. RESULTS Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03). CONCLUSION TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making.
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Affiliation(s)
| | | | | | - Joan Kub
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Grace Ho
- Johns Hopkins University, Baltimore, Maryland
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Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role. Behav Sci (Basel) 2017; 7:bs7020036. [PMID: 28590407 PMCID: PMC5485466 DOI: 10.3390/bs7020036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/12/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022] Open
Abstract
End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.
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Aslakson RA, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Yang T, Weiss M, Volandes AE, Bridges JFP, Roter DL. Utilising advance care planning videos to empower perioperative cancer patients and families: a study protocol of a randomised controlled trial. BMJ Open 2017; 7:e016257. [PMID: 28592584 PMCID: PMC5726140 DOI: 10.1136/bmjopen-2017-016257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Despite positive health outcomes associated with advance care planning (ACP), little research has investigated the impact of ACP in surgical populations. Our goal is to evaluate how an ACP intervention video impacts the patient centredness and ACP of the patient-surgeon conversation during the presurgical consent visit. We hypothesise that patients who view the intervention will engage in a more patient-centred communication with their surgeons compared with patients who view a control video. METHODS AND ANALYSIS Randomised controlled superiority trial of an ACP video with two study arms (intervention ACP video and control video) and four visits (baseline, presurgical consent, postoperative 1 week and postoperative 1 month). Surgeons, patients, principal investigator and analysts are blinded to the randomisation assignment. SETTING Single, academic, inner city and tertiary care hospital. Data collection began July 16, 2015 and continues to March 2017. PARTICIPANTS Patients recruited from nine surgical oncology clinics who are undergoing major cancer surgery. INTERVENTIONS In the intervention arm, patients view a patient preparedness video developed through extensive engagement with patients, surgeons and other stakeholders. Patients randomised to the control arm viewed an informational video about the hospital surgical programme. MAIN OUTCOMES AND MEASURES Primary Outcome: Patient centredness and ACP of patient-surgeon conversations during the presurgical consent visit as measured through the Roter Interaction Analysis System. SECONDARY OUTCOMES patient Hospital Anxiety and Depression Scale score; patient goals of care; patient, companion and surgeon satisfaction; video helpfulness; medical decision maker designation; and the frequency patients watch the video. Intent-to-treat analysis will be used to assess the impact of video assignment on outcomes. Sensitivity analyses will assess whether there are differential effects contingent on patient or surgeon characteristics. ETHICS AND DISSEMINATION This study has been approved by the Johns Hopkins School of Medicine institutional review board and is registered on clinicaltrials.gov (NCT02489799, First received: July 1, 2015). TRIAL REGISTRATION NUMBER clinicaltrials.gov, NCT02489799.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Oncology and Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Norah L Crossnohere
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alison M Conca-Cheng
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ting Yang
- Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Angelo E Volandes
- Department of Medicine, Massachusetts General Hospital, Boston, Maryland, USA
| | - John F P Bridges
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Debra L Roter
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Anxiety, depression and PTSD-related symptoms in spouses and close relatives of burn survivors: When the supporter needs to be supported. Burns 2017; 43:592-601. [DOI: 10.1016/j.burns.2016.09.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/08/2016] [Accepted: 09/25/2016] [Indexed: 11/23/2022]
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Koss CS, Baker TA. Where There’s a Will: The Link Between Estate Planning and Disparities in Advance Care Planning by White and Black Older Adults. Res Aging 2017; 40:281-302. [DOI: 10.1177/0164027517697116] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Data from the Health and Retirement Study ( n = 6,946) were used to test whether differences in estate planning accounted for disparities in advance care planning between White and Black older adults. White participants were more likely to have advance directives after controlling for demographic, health, and financial variables. When estate planning was also controlled, the odds of having an advance directive were equal for White and Black participants. In contrast, Whites remained more likely to discuss end-of-life preferences after controlling for demographic, health, financial, and estate planning variables. White participants were almost four times as likely to have wills or trusts. Wealth, income, and home ownership were predictive of estate planning. Financial disparities contributed to lower rates of estate planning which in turn explained in large part why Black older adults were less likely to have advance directives but did not account for race disparities in advance care discussion.
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Affiliation(s)
| | - Tamara A. Baker
- Department of Psychology, University of Kansas, Lawrence, KS, USA
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Reinke LF, Feemster LC, McDowell J, Gunnink E, Tartaglione EV, Udris E, Curtis JR, Au DH. The long term impact of an end-of-life communication intervention among veterans with COPD. Heart Lung 2017; 46:30-34. [PMID: 27989399 PMCID: PMC5581983 DOI: 10.1016/j.hrtlng.2016.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 10/05/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess if an end-of-life communication intervention with patients with COPD led to higher long-term documentation of advance care planning discussions at the end-of-life. BACKGROUND We previously demonstrated that providing clinicians a patient-specific feedback form about patients' communication preferences improved the occurrence and quality of clinician communication about end-of-life care. METHODS Among those individuals enrolled in the intervention study (2004-2007) who had died during the follow-up period (up to 2013), we assessed if patients in the intervention arm had more goals of care discussions and formal advance directives completed as compared to controls. We conducted logistic models accounting for provider level clustering, adjusting for age, FEV1, and race. RESULTS Among the 376 patients in the study, 157 died (76 in the intervention arm, 81 in the control arm). Over an average duration of 3.6 years (from the time of the first study appointment to death), 115 (73%) patients engaged in 451 unique end-of-life care discussions. The intervention was not associated with a higher percentage of patients with documented end-of-life conversations (I:C 75% vs 72%, p = 0.63) or completion of advance care directives (26% vs 29%, p = 0.55). CONCLUSIONS Despite initially improving the occurrence of end-of-life conversations, the intervention did not increase the documentation of subsequent conversations about end-of-life care, nor did it improve documentation of advance directives. Future research should focus on testing multi-faceted, longitudinal, system-level interventions to enhance conversations about goals of care that promote goal-concurrent care.
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Affiliation(s)
- Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA; University of Washington, School of Nursing, Department of Biobehavioral Nursing and Health Systems, USA.
| | - Laura C Feemster
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA; University of Washington, School of Medicine, Division of Pulmonary and Critical Care Medicine, USA
| | - Jennifer McDowell
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA
| | - Eric Gunnink
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA
| | - Erica V Tartaglione
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA
| | - Edmunds Udris
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA
| | - J Randall Curtis
- University of Washington, School of Medicine, Division of Pulmonary and Critical Care Medicine, USA
| | - David H Au
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, USA; University of Washington, School of Medicine, Division of Pulmonary and Critical Care Medicine, USA
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Fried T, Zenoni M, Iannone L. A Dyadic Perspective on Engagement in Advance Care Planning. J Am Geriatr Soc 2016; 65:172-178. [PMID: 27910091 DOI: 10.1111/jgs.14497] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning (ACP). DESIGN Qualitative cross-sectional study. SETTING Community. PARTICIPANTS Thirty-one veterans age 55 years and older and their surrogates. MEASUREMENTS In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred. RESULTS Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates' need for more detailed information, surrogates' lack of readiness to hear what the patient was saying, and surrogates' reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement. CONCLUSION Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients' and surrogates' attitudes and help to facilitate clear communication between them.
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Affiliation(s)
- Terri Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lynne Iannone
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
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Withdrawal of life-sustaining treatment: patient and proxy agreement: a secondary analysis of "contracts, covenants, and advance care planning". Dimens Crit Care Nurs 2016; 34:91-9. [PMID: 25650494 DOI: 10.1097/dcc.0000000000000097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Families of critically ill patients often make difficult decisions related to end-of-life (EOL) care including the withdrawal of life-sustaining therapies. OBJECTIVES This study explored patient and proxy decisions related to mechanical ventilator withdrawal in scenarios characterizing 3 distinct disease trajectories (cancer, stroke, and heart failure [HF]) with different prognoses. The relationship between patient directives, modification of directives, prognosis, trust, and EOL decisions were examined. METHODS This secondary analysis of data obtained in the "Contracts, Covenants, and Advance Care Planning" study included a sample of 110 subjects with 50 patient-proxy pairs. Patient and proxy agreement was assessed in response to questions regarding mechanical ventilator withdrawal while considering directives or modification of directives in 3 different scenarios. RESULTS Patient and proxy agreement ranged from 48% (n = 24 pairs) to 94% (n = 47 pairs). Agreement was lowest in HF (uncertain prognosis) when the directive indicated "do nothing" or "did not indicate any preference." Modified directives yielded 48% (n = 24 pairs) to 84% (n = 42 pairs) agreement. Changing directives from "do nothing" to "more hopeful" in HF (uncertain prognosis) had the highest agreement among modified scenarios. Despite wide variability in agreement, patients reported a high level of trust in their proxies' decisions. DISCUSSION This study highlighted differences in patient and proxy agreement about withdrawal of mechanical ventilation. Critical care nurses provide a key role in supporting EOL decisions. Encouraging ongoing communication about preferences and understanding the role of disease process and prognosis in decision making are paramount. Future research needs to explore factors that may improve patient and proxy agreement in EOL decisions and ways critical care nurses can support patients and proxies in these decisions, ultimately improving EOL care.
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McDonald JC, du Manoir JM, Kevork N, Le LW, Zimmermann C. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 2016; 25:523-531. [DOI: 10.1007/s00520-016-3433-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/26/2016] [Indexed: 11/25/2022]
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Köse I, Zincircioğlu Ç, Öztürk YK, Çakmak M, Güldoğan EA, Demir HF, Şenoglu N, Erbay RH, Gonullu M. Factors Affecting Anxiety and Depression Symptoms in Relatives of Intensive Care Unit Patients. J Intensive Care Med 2016; 31:611-7. [DOI: 10.1177/0885066615595791] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/23/2015] [Indexed: 11/16/2022]
Abstract
Aim: To determine the incidences of anxiety and depression in relatives of patients admitted to an intensive care unit (ICU) and to investigate the relationships between psychological symptoms and demographic features of the patients and their relatives. Methodology: Relatives of 78 ICU patients were enrolled in the study. Sociodemographic features of patients and their relatives were recorded. The Turkish version of the Hospital Anxiety and Depression Scale was used to assess anxiety and depression. Results: Twenty-eight (35.9%) cases with anxiety and 56 (71.8%) cases with depression were identified. The mean anxiety and depression scores were 9.49 ± 4.183 and 9.40 ± 4.286, respectively. Anxiety ( P = .028) and concomitant anxiety with depression ( P = .035) were more frequent among family members of young patients. The relationship to the patient, especially being a spouse, was significantly associated with symptoms (anxiety, P = .009; depression, P = .019; and both, P = .005). Conclusion: Spouses and family members of relatively young patients had higher rates of anxiety and depression. In contrast to the literature, depression was more common than anxiety among the relatives of ICU patients. Further research is needed on the impact of cultural and regional differences on anxiety and depression rates in family members of ICU patients.
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Affiliation(s)
- Işıl Köse
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Çiler Zincircioğlu
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Yasemin Kılıç Öztürk
- Department of Family Medicine, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Meltem Çakmak
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | | | - Hafize Fisun Demir
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Balıkesir University, Balıkesir, Turkey
| | - Nimet Şenoglu
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Rıza Hakan Erbay
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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Abstract
OBJECTIVE Rates of advance directive completion have increased over the past decade, but significant race differences remain. This study examined how overall increases in advance directive completion have affected disparities between White and African American older adults. METHOD Data were taken from the Health and Retirement Study (HRS). Using logistic regression models, the odds of having an advance directive among a sample of older African Americans and Whites who died between 2001 and 2012 were compared ( N = 5,832). RESULTS Odds for African Americans were 16% of the odds for Whites, p < .001, 95% confidence interval (CI) = [0.11, 0.23]. There were no significant interactions between race and year of death before 2010. During 2010-2012, the increase in the odds for African Americans was greater than for Whites, odds ratio (OR) = 1.95, p = .02, 95% CI = [1.14, 3.35]. DISCUSSION Although race disparities remain, the gap between Whites and African Americans has begun to narrow.
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Fine RL, Yang Z, Spivey C, Boardman B, Courtney M. Early experience with digital advance care planning and directives, a novel consumer-driven program. Proc (Bayl Univ Med Cent) 2016; 29:263-7. [PMID: 27365867 DOI: 10.1080/08998280.2016.11929430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Barriers to traditional advance care planning (ACP) and advance directive (AD) creation have limited the promise of ACP/AD for individuals and families, the healthcare team, and society. Our objectives were to determine the results of a digital ACP/AD through which consumers create, store, locate, and retrieve their ACP/AD at no charge and with minimal physician involvement, and the ACP/AD can be integrated into the electronic health record. The authors chose 900 users of MyDirectives, a digital ACP/AD tool, to achieve proportional representation of all 50 states by population size and then reviewed their responses. The 900 participants had an average age of 50.8 years (SD = 16.6); 84% of the men and 91% of the women were in self-reported good health when signing their ADs. Among the respondents, 94% wanted their physicians to consult a supportive and palliative care team if they were seriously ill; nearly 85% preferred cessation of life-sustaining treatments during their final days; 76% preferred to spend their final days at home or in a hospice; and 70% would accept attempted cardiopulmonary resuscitation in limited circumstances. Most respondents wanted an autopsy under certain conditions, and 62% wished to donate their organs. In conclusion, analysis of early experience with this ACP/AD platform demonstrates that individuals of different ages and conditions can engage in an interrogatory process about values, develop ADs that are more nuanced than traditional paper-based ADs in reflecting those values, and easily make changes to their ADs. Online ADs have the potential to remove barriers to ACP/AD and thus further improve patient-centered end-of-life care.
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Affiliation(s)
- Robert L Fine
- Office of Clinical Ethics and Palliative Care, Baylor Scott and White Health, Dallas, Texas (Fine); and the College of Business (Yang, Spivey), College of Engineering (Boardman), and College of Nursing and Health Innovation (Courtney), The University of Texas at Arlington, Arlington, Texas
| | - Zhiyong Yang
- Office of Clinical Ethics and Palliative Care, Baylor Scott and White Health, Dallas, Texas (Fine); and the College of Business (Yang, Spivey), College of Engineering (Boardman), and College of Nursing and Health Innovation (Courtney), The University of Texas at Arlington, Arlington, Texas
| | - Christy Spivey
- Office of Clinical Ethics and Palliative Care, Baylor Scott and White Health, Dallas, Texas (Fine); and the College of Business (Yang, Spivey), College of Engineering (Boardman), and College of Nursing and Health Innovation (Courtney), The University of Texas at Arlington, Arlington, Texas
| | - Bonnie Boardman
- Office of Clinical Ethics and Palliative Care, Baylor Scott and White Health, Dallas, Texas (Fine); and the College of Business (Yang, Spivey), College of Engineering (Boardman), and College of Nursing and Health Innovation (Courtney), The University of Texas at Arlington, Arlington, Texas
| | - Maureen Courtney
- Office of Clinical Ethics and Palliative Care, Baylor Scott and White Health, Dallas, Texas (Fine); and the College of Business (Yang, Spivey), College of Engineering (Boardman), and College of Nursing and Health Innovation (Courtney), The University of Texas at Arlington, Arlington, Texas
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Berry M, Brink E, Metaxa V. Time for change? A national audit on bereavement care in intensive care units. J Intensive Care Soc 2016; 18:11-16. [PMID: 28979531 DOI: 10.1177/1751143716653770] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Bereaved ICU family members frequently experience anxiety, depression and post-traumatic stress disorder, which have been associated with significantly impaired quality of life. Recognising that their needs extend beyond the support provided by their friends and family, the Intensive Care Society had published in 1998 recommendations around bereavement care. OBJECTIVE The aim of the present national audit was to compare bereavement services in England against the nine recommendations set out by the Intensive Care Society guidelines. METHODS A telephone audit was carried out in all adult ICUs in England. RESULTS A total of 144 NHS Trusts (179 ICUs) met the inclusion criteria and 113 responses were collected (78% of Trusts, 63% of individual ICUs). Although most ICUs provided administrative information (96% had an information booklet), training (53%), auditing (19%) and adequate facilities (27%) did not meet the recommended standards. CONCLUSION Bereavement care is underdeveloped in English ICUs. This important but underreported topic should be prioritised in the critical care research agenda.
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Affiliation(s)
- M Berry
- Imperial School of Anaesthesia, London, UK
| | - E Brink
- King's College Hospital, London, UK
| | - V Metaxa
- King's College Hospital, London, UK
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The Family Communication Study: A randomized trial of prospective pediatric palliative care consultation, study methodology and perceptions of participation burden. Contemp Clin Trials 2016; 49:15-20. [PMID: 27263074 DOI: 10.1016/j.cct.2016.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/20/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND To describe the study methods, baseline characteristics and burden of study procedures of an intervention designed to reduce family stress symptoms through early support from the palliative care team. Length of stay of ≥8days was the trigger for early palliative care involvement. METHODS Cluster-randomized trial with children as the unit of randomization. Up to 3 family members per child were recruited. Family stress symptoms were recorded at baseline, discharge from the ICU, and 3months post-enrollment. Questionnaire burden was assessed on a 1-10 point scale at each time point and open-ended comments were analyzed to describe the participants' experience in the study. RESULTS 380 family members of 220 children (control=115 children and 204 family members; intervention=105 children and 176 family members) were recruited, which represented 50% of all eligible families. Most family participants were parents (86% control; 92% intervention) and female (66% both groups). Retention rates were high through the 3-month follow-up: 93% and 90% for the control and intervention groups respectively. Questionnaire burden was very low: mean (sd) scores were 1.1 (1.6), 0.7 (1.5), and 0.9 (1.6) for the baseline, discharge and follow-up questionnaires, respectively. Comments suggest that participation was beneficial by promoting reflection and self-awareness about stress, coping and resilience, and feeling cared for because the intervention and questionnaires focused on their own well-being. CONCLUSIONS The participants' comments regarding the focus on them as the point of intervention reflects the value of conducting research with family members of seriously ill children during ICU stays.
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Price J. Informed shared decision-making in planning for the end of life. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2016; 25:378-83. [PMID: 27081732 DOI: 10.12968/bjon.2016.25.7.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In recent years, a number of shortcomings in the NHS have been identified in end-of-life care delivered in hospital for people with long-term conditions other than terminal cancer. This article gives an overview of the findings of a Dignity in Care travel scholarship, which was undertaken to establish whether an American shared informed decision aid, specifically designed to initiate therapeutic conversations for this patient group, might reasonably be adopted in an NHS setting. One tool specifically for this purpose was in use in the USA at the time, and its efficacy formed part of a broader research study being carried out at Dartmouth Hitchcock Medical Center (DHMC) in New England. Concurrently in the UK, The Health Foundation supported a 3-year study that focused exclusively on the development of a range of 'option grids' for clinical interventions and did not include an end-of-life model.
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Affiliation(s)
- Jane Price
- Patient Experience Lead Nurse, Corporate Nursing Team, Aneurin Bevan University Health Board, Wales
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Hansen L. How experienced intensive care nurses communicate with families about shift to end-of-life care. Evid Based Nurs 2016; 19:48. [PMID: 26643059 DOI: 10.1136/eb-2015-102154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Lissi Hansen
- Oregon Health & Science University, Portland, Oregon, USA
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Acutely Bereaved Surrogates' Stories About the Decision to Limit Life Support in the ICU. Crit Care Med 2016; 43:2387-93. [PMID: 26327201 DOI: 10.1097/ccm.0000000000001270] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Participating in a decision to limit life support for a loved one in the ICU is associated with adverse mental health consequences for surrogate decision makers. We sought to describe acutely bereaved surrogates' experiences surrounding this decision. DESIGN Qualitative analysis of interviews with surrogates approximately 4 weeks after a patient's death in one of six ICUs at four hospitals in Pittsburgh, PA. SUBJECTS Adults who participated in decisions about life support in the ICU. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS We collected participant demographics, previous advance care planning, and decision control preferences. We used qualitative content analysis of transcribed interviews to identify themes in surrogates' experiences. The 23 participants included the spouse (n = 7), child/stepchild (7), sibling (5), parent (3), or other relation (1) of the deceased patient. Their mean age was 55, 61% were women, all were whites, 74% had previous treatment preference discussions with the patient, and 43% of patients had written advance directives. Fifteen of 23 surrogates (65%) preferred an active decision-making role, 8 of 23 (35%) preferred to share responsibility with the physician, and no surrogates preferred a passive role. Surrogates report that key stressors in the ICU are the uncertainty and witnessed or empathic suffering. These factors contributed to surrogates' sense of helplessness in the ICU. Involvement in the decision to limit life support allowed surrogates to regain a sense of agency by making a decision consistent with the patient's wishes and values, counteracting surrogates' helplessness and ending the uncertainty and suffering. CONCLUSIONS In this all-white sample of surrogates with nonpassive decision control preferences from a single US region, participating in decision making allowed surrogates to regain control, counteract feelings of helplessness, and end their empathic suffering. Although previous research highlighted the distress caused by participation in a decision to limit life support, the act of decision making may, counterintuitively, help some surrogates cope with the experience.
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Olsen DP. Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care. J Am Psychiatr Nurses Assoc 2016; 22:52-9. [PMID: 26929232 DOI: 10.1177/1078390316629958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care. OBJECTIVE Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed. DESIGN These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent. RESULTS Specific recommendations are offered. CONCLUSIONS Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.
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Affiliation(s)
- Douglas P Olsen
- Douglas P. Olsen, PhD, RN, Michigan State University College of Nursing, East Lansing, MI, USA
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