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Park D, Son D, Hamada T, Imaoka S, Lee Y, Kamimoto M, Inoue K, Matsumoto H, Shimosaka T, Sasaki S, Koda M, Taniguchi SI. The Effectiveness of the Multiple-Attending-Physicians System Compared With the Single Attending-Physician System in Inpatient Setting: A Mixed-Method Study. J Prim Care Community Health 2023; 14:21501319231175054. [PMID: 37191304 DOI: 10.1177/21501319231175054] [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: 05/17/2023] Open
Abstract
OBJECTIVES Medical facilities have been required to effectively utilize insufficient human resources in many countries. Therefore, we qualitatively and quantitively compared physicians' working burden, and assessed advantages and disadvantages of the single- and the multiple-attending physicians systems in inpatient care. METHODS In this cross-sectional study, we extracted electronic health record of patients from a hospital in Japan from April 2017 to October 2018 to compare anonymous statistical data between the single-attending and multiple-attending-physicians system. Then, we conducted a questionnaire survey for all physicians of single and multiple-attending systems, asking about their physical and psychiatric workload, and their reasons and comments on their working styles. RESULTS The average length of hospital stay was significantly shorter in the multiple-attending system than in the single-attending system, while patients' age, gender, and diagnoses were similar. From the questionnaire survey, no significant difference was found in all categories although physical burden in multiple-attending system tended to be lower than that in single-attending system. Advantages of multiple-attending system extracted from qualitative analysis are (1) improvement of physicians' quality of life (QOL), (2) lifelong-learning effect, and (3) improving the quality of medical care, while disadvantages were (1) risk of miscommunications, (2) conflicting treatment policies among physicians, and (3) patients' concern. CONCLUSIONS The multiple-attending physician system in the inpatient setting can reduce the average length of stay for patients and also reduce the physical burden on physicians without compromising their clinical performance.
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Affiliation(s)
- Daeho Park
- Family Clinic Kakogawa, Kakogawa, Hyogo, Japan
| | - Daisuke Son
- Tottori University, Yonago, Tottori, Japan
- Hino Hospital, Hino, Tottori, Japan
| | | | - Shintaro Imaoka
- Tottori University, Yonago, Tottori, Japan
- Hino Hospital, Hino, Tottori, Japan
| | - Young Lee
- Tottori University, Yonago, Tottori, Japan
- Hino Hospital, Hino, Tottori, Japan
| | | | - Kazuoki Inoue
- National Health Insurance Daisen Clinic, Saihaku-gun, Tottori, Japan
| | - Hiromi Matsumoto
- Kawasaki University of Medical Welfare, Kurashiki, Okayama, Japan
| | | | | | | | - Shin-Ichi Taniguchi
- Tottori University, Yonago, Tottori, Japan
- Hino Hospital, Hino, Tottori, Japan
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2
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Murphy AC, Schultz KC, Gao S, Morales AM, Barnato AE, Fanning JB, Hall DE. Prudence in end-of-life decision making: A virtue-based analysis of physician communication with patients and surrogates. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100182. [PMID: 36582622 PMCID: PMC9797053 DOI: 10.1016/j.ssmqr.2022.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite significant improvements in end-of-life care over several decades, belated hospice referrals and hospital staffing patterns make challenging end-of-life conversations between strangers unsurprising, especially when the interaction is time-sensitive. Understanding how physicians perform under these circumstances is relevant to patient quality and medical education. This study is a secondary analysis of transcripts from a simulation that placed 88 intensivists, hospitalists, and ED physicians in the setting of responding to a nurse's call to evaluate a floor patient for impending respiratory collapse. A philosophical account of prudence guided the analytical approach and was operationalized through behavior-based and exemplar-based qualitative coding strategies. Exemplary performances and specific behaviors were then compared with preferred outcomes. Results indicate that exemplary performance correlated with a cluster of 3 behaviors that predicted the desired outcomes, but did not determine them: (1) directly affirming the likelihood that the patient will die in the near term; (2) explicitly soliciting the patient's preferences for care; and (3) asking what other family and friends should be involved. The current study implies that educational initiatives aimed at improving end-of-life conversations should expose clinicians both to technical competencies and to the virtues required to employ these competencies well.
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Affiliation(s)
- Alan C. Murphy
- Kaiser Permanente Baldwin Park, 1011 Baldwin Park Blvd, Baldwin Park, CA 91706, USA,Corresponding author. (A.C. Murphy)
| | - Kevan C. Schultz
- Center for Social and Urban Research, University of Pittsburgh, 3343 Forbes Avenue, Pittsburgh, PA, 15260, USA
| | - ShaSha Gao
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA
| | - Andre M. Morales
- Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, 1313 21st Ave South, Nashville, TN, 37203, USA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03766, USA
| | - Joseph B. Fanning
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 400, Nashville, TN, 37203, USA
| | - Daniel E. Hall
- General Surgery, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA,General Surgery, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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3
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Leland B, Wocial L. Exploring Ethical Dimensions of Physician Involvement in Requests for Organ Donation in Pediatric Brain Death. Semin Pediatr Neurol 2022; 45:101031. [PMID: 37003625 DOI: 10.1016/j.spen.2022.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/16/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
Pediatric organ transplantation remains a life-saving therapy, with donated organs being absolutely scarce resources. Efforts to both increase pediatric organ donation authorization by families of children declared dead by neurologic criteria and mitigate perception of conflicts of interest have resulted in frequent exclusion of physicians from this process. This article provides of focused review of pediatric organ donation in the setting of brain death, explores the breadth of consequences of physician exclusion in donation authorization requests, and provides an ethical framework defending physician involvement in the organ donation process for this patient population.
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4
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Grignoli N, Di Bernardo V, Malacrida R. New perspectives on substituted relational autonomy for shared decision-making in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:260. [PMID: 30309384 PMCID: PMC6182794 DOI: 10.1186/s13054-018-2187-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022]
Abstract
In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients’ preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.
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Affiliation(s)
- Nicola Grignoli
- Sasso Corbaro Medical Humanities Foundation, Via Lugano 4b, CH-6500, Bellinzona, Switzerland. .,Clinical Ethics Commission, Ente Ospedaliero Cantonale, CH-6500, Bellinzona, Switzerland. .,Psychiatry Consultation Liaison Service, Organizzazione Sociopsichiatrica Cantonale, CH-6850, Mendrisio, Switzerland.
| | - Valentina Di Bernardo
- Sasso Corbaro Medical Humanities Foundation, Via Lugano 4b, CH-6500, Bellinzona, Switzerland.,Clinical Ethics Commission, Ente Ospedaliero Cantonale, CH-6500, Bellinzona, Switzerland.,Intensive Care Unit, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, CH-6900, Lugano, Switzerland
| | - Roberto Malacrida
- Sasso Corbaro Medical Humanities Foundation, Via Lugano 4b, CH-6500, Bellinzona, Switzerland
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5
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Butler R, Monsalve M, Thomas GW, Herman T, Segre AM, Polgreen PM, Suneja M. Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network. Am J Med 2018; 131:972.e9-972.e15. [PMID: 29649458 DOI: 10.1016/j.amjmed.2018.03.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers. METHODS We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers. RESULTS For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists). CONCLUSIONS Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined.
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Affiliation(s)
- Rachel Butler
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Mauricio Monsalve
- Department of Epidemiology, University of Iowa, Iowa City; Centro de Investigación para la Gestión Integrada de Desastres Naturales, Santiago, Chile
| | - Geb W Thomas
- Department of Mechanical and Industrial Engineering, University of Iowa, Iowa City
| | - Ted Herman
- Department of Computer Science, University of Iowa, Iowa City
| | - Alberto M Segre
- Department of Computer Science, University of Iowa, Iowa City
| | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City; Department of Epidemiology, University of Iowa, Iowa City
| | - Manish Suneja
- Department of Internal Medicine, University of Iowa, Iowa City.
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6
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Leland BD, Torke AM, Wocial LD, Helft PR. Futility Disputes: A Review of the Literature and Proposed Model for Dispute Navigation Through Trust Building. J Intensive Care Med 2016; 32:523-527. [PMID: 27568477 DOI: 10.1177/0885066616666001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Futility disputes in the intensive care unit setting have received significant attention in the literature over the past several years. Although the idea of improving communication in an attempt to resolve these challenging situations has been regularly discussed, the concept and role of trust building as the means by which communication improves and disputes are best navigated is largely absent. We take this opportunity to review the current literature on futility disputes and argue the important role of broken trust in these encounters, highlighting current evidence establishing the necessity and utility of trust in both medical decision-making and effective communication. Finally, we propose a futility dispute navigation model built upon improved communication through trust building.
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Affiliation(s)
- Brian D Leland
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,2 Department of Pediatrics, Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexia M Torke
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,3 Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.,4 Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indiana University Health, Indianapolis, IN, USA
| | - Lucia D Wocial
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,5 Indiana University School of Nursing, Indianapolis, IN, USA
| | - Paul R Helft
- 1 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,6 Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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7
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Amin P, Fox-Robichaud A, Divatia JV, Pelosi P, Altintas D, Eryüksel E, Mehta Y, Suh GY, Blanch L, Weiler N, Zimmerman J, Vincent JL. The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 35:223-8. [PMID: 27444985 DOI: 10.1016/j.jcrc.2016.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 06/12/2016] [Indexed: 01/24/2023]
Abstract
The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist.
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Affiliation(s)
- Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India.
| | | | | | | | | | | | | | - Gee Young Suh
- Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Lluís Blanch
- Universitat Autònoma de Barcelona, CIBERes, Parc Taulí Hospital, Sabadell, Spain
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8
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Hoff T, Collinson GE. How Do We Talk About the Physician-Patient Relationship? What the Nonempirical Literature Tells Us. Med Care Res Rev 2016; 74:251-285. [PMID: 27147640 DOI: 10.1177/1077558716646685] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The physician-patient relationship is an important ideal, and a construct central to discussions regarding health systems change and innovation. This review examines the nonempirical literature focused on the physician-patient relationship published over the past 15 years. The review's results show a literature that is heavily context bound, relies on a combination of informational and emotional appeals to influence readers, and is mostly focused on portraying the state of this relationship in negative ways. Characteristics of the relationship such as trust, communication, and information are particularly focused on, while other important features like empathy remain less addressed. The review's findings suggest broadening the perspective regarding how the physician-patient relationship is construed, in order to take advantage of its increased importance in the modern health care marketplace, and to account for new relational dynamics between providers and patients suggested by innovations in care delivery.
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9
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Hrisos S, Thomson R. Seeing it from both sides: do approaches to involving patients in improving their safety risk damaging the trust between patients and healthcare professionals? An interview study. PLoS One 2013; 8:e80759. [PMID: 24223230 PMCID: PMC3819291 DOI: 10.1371/journal.pone.0080759] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/20/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Encouraging patients to be more vigilant about their care challenges the traditional dynamics of patient-healthcare professional interactions. This study aimed to explore, from the perspectives of both patients and frontline healthcare staff, the potential consequences of patient-mediated intervention as a way of pushing safety improvement through the involvement of patients. DESIGN Qualitative study, using purposive sampling and semi-structured interviews with patients, their relatives and healthcare professionals. Emergent themes were identified using grounded theory, with data coded using NVIVO 8. PARTICIPANTS 16 patients, 4 relatives, (mean age (sd) 60 years (15); 12 female, 8 male) and 39 healthcare professionals, (9 pharmacists, 11 doctors, 12 nurses, 7 health care assistants). SETTING Participants were sampled from general medical and surgical wards, taking acute and elective admissions, in two hospitals in north east England. RESULTS Positive consequences were identified but some actions encouraged by current patient-mediated approaches elicited feelings of suspicion and mistrust. For example, patients felt speaking up might appear rude or disrespectful, were concerned about upsetting staff and worried that their care might be compromised. Staff, whilst apparently welcoming patient questions, appeared uncertain about patients' motives for questioning and believed that patients who asked many questions and/or who wrote things down were preparing to complain. Behavioural implications were identified that could serve to exacerbate patient safety problems (e.g. staff avoiding contact with inquisitive patients or relatives; patients avoiding contact with unreceptive staff). CONCLUSIONS Approaches that aim to push improvement in patient safety through the involvement of patients could engender mistrust and create negative tensions in the patient-provider relationship. A more collaborative approach, that encourages patients and healthcare staff to work together, is needed. Future initiatives should aim to shift the current focus away from "checking up" on individual healthcare professionals to one that engages both parties in the common goal of enhancing safety.
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Affiliation(s)
- Susan Hrisos
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Thomson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
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10
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Higginson IJ, Koffman J, Hopkins P, Prentice W, Burman R, Leonard S, Rumble C, Noble J, Dampier O, Bernal W, Hall S, Morgan M, Shipman C. Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty. BMC Med 2013; 11:213. [PMID: 24083470 PMCID: PMC3850793 DOI: 10.1186/1741-7015-11-213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult. METHODS Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher's exact test (for non-normally distributed characteristics) and the Mann-Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded. RESULTS PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann-Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not. CONCLUSIONS PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, School of Medicine, Bessemer Road, Denmark Hill, London SE5 9PJ, UK.
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11
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Thüm S, Janssen C, Pfaff H, Lefering R, Neugebauer EA, Ommen O. The association between psychosocial care by physicians and patients' trust: a retrospective analysis of severely injured patients in surgical intensive care units. PSYCHO-SOCIAL MEDICINE 2012; 9:Doc04. [PMID: 23049644 PMCID: PMC3461762 DOI: 10.3205/psm000082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Trust is an essential element in physician-patient interaction fostering in general adherence and improving patient- and physician-reported outcomes. Regarding severely injured patients, trust-building behaviour is important because of the severity of injuries and therefore potential associated physical and psychological consequences. The objective of this study was to identify significant and relevant determinants on trust of severely injured patients in their physicians in surgical intensive care units. METHODS Ninety-one severely injured patients completed a self-administered questionnaire after being transferred from surgical intensive care unit to surgical unit. All patients were treated in four hospitals of maximal care in North Rhine-Westphalia between 2001 and 2005. To assess different aspects of trust the "trust in physician" scale of the Cologne Patient Questionnaire (CPQ) was used. "Psychosocial care by physicians" is measured through: support, devotion, information and shared-decision making provided by physicians. Patient- and trauma related control variables are also included in a logistic regression model. RESULTS Stepwise logistic regression identified "psychosocial care provided by physicians" as a significant contributor to severely injured patients' trust (Nagelkerke's R(2): 41%). "Trust in physicians" is correlated with all four dimensions of "psychosocial care by physicians": support (0.546), devotion (0.443), information (0.396), and shared-decision making behaviour (0.342) provided by physicians in surgical intensive care units. CONCLUSIONS This finding confirms the importance of supportive communication style in physician-patient interaction concerning reported trust of severely injured patients on surgical intensive care units. Medical education should integrate sound knowledge about psychosocial aspects of interaction to provide effective emotional and informational support to build up and maintain patient trust.
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Affiliation(s)
- Sonja Thüm
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
| | - Christian Janssen
- Faculty of Applied Social Sciences, University of Applied Sciences Munich, Germany
| | - Holger Pfaff
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Faculty of Medicine, University of Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
| | - Edmund A. Neugebauer
- Institute for Research in Operative Medicine, Faculty of Medicine, University of Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
| | - Oliver Ommen
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
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12
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Garcia-Retamero R, Galesic M. Does young adults' preferred role in decision making about health, money, and career depend on their advisors' leadership skills? INTERNATIONAL JOURNAL OF PSYCHOLOGY 2012; 48:492-501. [PMID: 22731631 DOI: 10.1080/00207594.2012.688135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Few empirical data exist on how decision making about health differs from that in other crucial life domains with less threatening consequences. To shed light on this issue we conducted a study with 175 young adults (average age 19 years). We presented the participants with scenarios involving advisors who provided assistance in making decisions about health, money, and career. For each scenario, participants were asked to what extent they wanted the advisor to exhibit several leadership styles and competencies and what role (active, collaborative, or passive) they preferred to play when making decisions. Results show that decision making about health is distinct from that in the other domains in three ways. First, most of the participants preferred to delegate decision making about their health to their physician, whereas they were willing to collaborate or play an active role in decision making about their career or money. Second, the competencies and leadership style preferred for the physician differed substantially from those desired for advisors in the other two domains: Participants expected physicians to show more transformational leadership--the style that is most effective in a wide range of environments--than those who provide advice about financial investments or career. Finally, participants' willingness to share medical decision making with their physician was tied to how strongly they preferred that the physician shows an effective leadership style. In contrast, motivation to participate in decision making in the other domains was not related to preferences regarding advisors' leadership style or competencies. Our results have implications for medical practice as they suggest that physicians are expected to have superior leadership skills compared to those who provide assistance in other important areas of life.
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13
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Baggs JG, Schmitt MH, Prendergast TJ, Norton SA, Sellers CR, Quinn JR, Press N. Who is attending? End-of-life decision making in the intensive care unit. J Palliat Med 2012; 15:56-62. [PMID: 22233466 PMCID: PMC3304246 DOI: 10.1089/jpm.2011.0307] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2011] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. METHODS Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. RESULTS The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. CONCLUSIONS Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.
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Affiliation(s)
- Judith Gedney Baggs
- School of Nursing, Oregon Health & Science University, Portland, Oregon 97239, USA.
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14
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Did you seek assistance for writing your advance directive? A qualitative study. Wien Klin Wochenschr 2010; 122:620-5. [PMID: 21120703 DOI: 10.1007/s00508-010-1470-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND the completion of an advanced directive is paired with a high degree of self-responsibility of the signatory. It requires anticipation of probably complex medical situations. In the literature, the family physician is often seen as the most important person for advice when writing an advance directive. But little is known about whether or not patients want to involve medical advisors and to what extent physicians are willing to give advice. The aim of this study was to analyse whether or not individuals approached advisors for the completion of their advance directive, whom they chose and which reasons were given for seeking or foregoing assistance. METHODS semi-structured interviews with healthy individuals, chronically ill individuals and patients in palliative care including questions associated with advice for completing an advance directive (8/2008-7/2009). INCLUSION CRITERIA age 55-70 years and advance directive ≥ 3 months old. The interviews were fully transcribed according to standard transcription rules and analysed applying an inductive category development. RESULTS interviews were conducted with 53 probands (healthy n = 20, chronically ill n = 17, palliative care patients n = 16); 18 probands were male. Mean age was 63.2 ± 4.4 years (range 55-70 years). Professional advice was sought by 12 probands (physician = 2, nurse = 1, lawyer/notary = 8, self-employed advisor = 1), another 8 probands included family members. In 17 cases, the physician knew the proband's advance directive, 36 probands never told their doctor about its existence. Categories of reasons for seeking or foregoing advice were trust/lack of trust, autonomy, rejection and financial considerations. CONCLUSIONS information about the medical implications concerning patient preferences for end-of-life care seems not to be the main focus of interest when individuals write an advance directive. Autonomy and trust into notarially certified documents seem to be more important matters. If family physicians want to have a role in their patients' completing of an advance directive, they should proactively get in touch with them.
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Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Care Med 2010; 182:905-9. [PMID: 20538959 DOI: 10.1164/rccm.201002-0262oc] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Surrogate decision makers and clinicians often have discordant perceptions about a patient's prognosis. There is a paucity of empirical data to guide communication about prognosis. OBJECTIVES To assess: (1) whether numeric or qualitative statements more reliably convey prognostic estimates; and (2) whether surrogates believe physicians' prognostic estimates. METHODS A total of 169 surrogate decision makers for intensive care unit patients were randomized to view 1 of 2 versions of a video portraying a simulated family conference involving a hypothetical patient. The videos varied only by whether prognosis was conveyed in numeric terms ("10% chance of surviving") or qualitative terms ("very unlikely" to survive). MEASUREMENTS AND MAIN RESULTS We assessed: (1) surrogates' personal estimates of the patient's prognosis; and (2) surrogates' understanding of the physician's prognostic estimate. Neither surrogates' personal estimates nor their understanding of the physician's prognostication differed when prognosis was conveyed numerically versus qualitatively (surrogates' estimate, 22 ± 23% chance of survival versus 26 ± 24%, P = 0.26; understanding of physician's estimate, 17 ± 22% chance of survival versus 16 ± 17%, P = 0.62). One in five surrogates estimated the patient's prognosis was greater than 20% more optimistic than the physician's prognostication. Less trust in physicians was associated with larger discrepancies between surrogates' personal estimates and their understanding of the physician's estimate. CONCLUSIONS Neither numeric nor qualitative statements reliably convey news of a poor prognosis to surrogates in intensive care units. Many surrogates do not view physicians' prognostications as absolutely accurate. Factors other than ineffective communication may contribute to physician-surrogate discordance about prognosis.
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Affiliation(s)
- Susan J Lee Char
- Department of Surgery, University of California, San Francisco, School of Medicine, USA
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Faith K, Chidwick P. Role of clinical ethicists in making decisions about levels of care in the intensive care unit. Crit Care Nurse 2009; 29:77-84. [PMID: 19339449 DOI: 10.4037/ccn2009285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Karen Faith
- Clinical Ethics Centre at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Rotenberg KJ, Cunningham J, Hayton N, Hutson L, Jones L, Marks C, Woods E, Betts LR. Development of a Children's Trust in General Physicians Scale. Child Care Health Dev 2008; 34:748-56. [PMID: 18959573 DOI: 10.1111/j.1365-2214.2008.00872.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Researchers have developed scales assessing adults' trust beliefs in physicians and found that those are associated with measures of health behaviour and physical health. The purpose of the research was to develop a Children's Trust in General Physicians Scale (CTGPS) and examine its relation to health behaviour: adherence to medical regimes. METHODS The participants were 128 children (68 girls and 60 boys) in Study 1 and 198 children (105 girls and 93 boys) in Study 2 who attended years 5 and 6 of elementary school in UK (mean ages = 10 years and 10 months and 10 years and 7 months respectively). The children completed the nine-item CTGPS and reported their trust in doctors and (in Study 2) adherence to medical regimes. Parents also reported those behaviours. RESULTS Principal components analysis and confirmatory factor analysis of the CTGPS yielded the expected three factors: Honesty, Emotional and Reliability. The CTGPS had acceptable internal consistency and, as evidence for its validity, was associated with reported trust in doctors. The results from Study 2 confirmed that the CTGPS was associated with adherence to medical regimes. CONCLUSION A CTGPS was developed that is associated with adherence to medical regimes.
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Affiliation(s)
- K J Rotenberg
- School of Psychology, Keele University, Keele, Staffordshire, UK.
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Sorensen R, Iedema R. Redefining accountability in health care: managing the plurality of medical interests. Health (London) 2008; 12:87-106. [DOI: 10.1177/1363459307083699] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of `futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment. We contend that managing the plurality of medical interests is essential in achieving a more managed and positive experience for patients and families of the care they receive, and for achieving standards of quality and resource use. From an ethnographic study undertaken in a large ICU in Sydney, Australia, we found that the knowledge and practice differences of multiple medical decision-makers generated conflict, inconsistency of practice and subjectivity of decision-making that impeded coherent clinical decision-making and integrated patient care planning, coordination and care review. Improving patients' and families' experience of care requires medical clinicians and medical managers to accept responsibility for institutionalizing effective communication and decision-making processes within clinical networks and between clinical and managerial domains. Thus, strategies to improve patient care will need to extend beyond the medical profession to incorporate administrative management. We conclude that restructuring communication and decision-making processes is imperative to achieve clinical accountability in the workplace and systems accountability in the organization.
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Bos AP, van Zwieten MCB. Randomized, controlled trials in the emergency setting: a matter of physician-patient relationships, responsibility, and trust. Crit Care Med 2007; 35:979-80. [PMID: 17421105 DOI: 10.1097/01.ccm.0000257366.71279.e8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mandell MS, Zamudio S, Seem D, McGaw LJ, Wood G, Liehr P, Ethier A, D'Alessandro AM. National evaluation of healthcare provider attitudes toward organ donation after cardiac death. Crit Care Med 2006; 34:2952-8. [PMID: 17075366 DOI: 10.1097/01.ccm.0000247718.27324.65] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Organ donation after cardiac death will save lives by increasing the number of transplantable organs. But many healthcare providers are reluctant to participate when the withdrawal of intensive care leads to organ donation. Prior surveys indicate ethical concerns as a barrier to the practice of organ donation after cardiac death, but the specific issues that characterize these concerns are unknown. We thus aimed to identify what barriers healthcare providers perceive. DESIGN We conducted a qualitative analysis of focus group transcripts to identify issues of broad importance. SETTING Healthcare setting. PARTICIPANTS Participants included 141 healthcare providers representing critical care and perioperative nurses, transplant surgeons, medical examiners, organ procurement personnel, neurosurgeons, and neurologists. INTERVENTIONS Collection and analysis of information regarding healthcare providers' attitudes and beliefs. MEASUREMENTS AND MAIN RESULTS All focus groups agreed that increased organ availability is a benefit but questioned the quality of organs recovered. Study participants identified a lack of standards for patient prognostication and cardiopulmonary death and a failure to prevent a conflict between patient and donor interests as obstacles to acceptance of organ donation after cardiac death. They questioned the practices and motives of colleagues who participate in organ donation after cardiac death, apprehensive that real or perceived impropriety would affect public perception. CONCLUSIONS Healthcare providers are uncomfortable at the clinical juncture where end-of-life care and organ donation interface. Our findings are consistent with theories that care providers are hesitant to perform medical tasks that they consider to be outside the focus of their practice, especially when there is potential conflict of interest. This conflict appears to impose moral distress on healthcare providers and limits acceptance of organ donation after cardiac death. Future research is warranted to examine the effect of standardized procedures on reducing moral distress. The hypothesis generated by this qualitative study is that use of neutral third parties to broach the subject of organ donation may improve acceptance of organ donation after cardiac death.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO, USA
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Mangram AJ, McCauley T, Villarreal D, Berne J, Howard D, Dolly A, Norwood S. Families’ Perception of the Value of Timed Daily “Family Rounds” in a Trauma ICU. Am Surg 2005. [DOI: 10.1177/000313480507101021] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Daily communications between the ICU trauma patients’ families and the trauma team are often limited due to the unpredictable nature of subsequent patient admissions and operative procedures. In order to improve the lines of family-physician communication and educate residents regarding family communication, our level I trauma center instituted daily “Family Rounds” (FR). FR occur at the same time every day, in the patient's ICU room. The purpose of this study was to determine whether families valued the scheduled daily FR, to establish whether FR improved the family-physician relationship, and to delineate strengths and weaknesses of the present structure of our FR. We mailed surveys to family members of trauma patients hospitalized in the trauma ICU for ≥3 days. A total of 55 (22%) families responded. Combining “excellent” and “good” responses, 86.5 per cent of families looked forward to having a specific time of day to meet with the trauma team, and 90 per cent liked having rounds in the ICU room with the patient. However, 36 per cent did not like having only scheduled time for FR. The majority, 75 per cent, believed that all concerns were addressed during FR, and 84.9 per cent rated their overall experience as either excellent or good. Scheduled FR appear to improve communication between trauma surgeons and patients’ families, enhance the family-physician relationship, and strengthen our surgical residency teaching program.
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Affiliation(s)
- Alicia J. Mangram
- Methodist Hospitals of Dallas, Trauma and Critical Care Services, Dallas, Texas
| | - T. McCauley
- East Texas Medical Center, Department of Trauma, Tyler, Texas
| | - D. Villarreal
- East Texas Medical Center, Department of Trauma, Tyler, Texas
| | - J. Berne
- East Texas Medical Center, Department of Trauma, Tyler, Texas
| | - D. Howard
- Methodist Hospitals of Dallas, Trauma Services, Dallas, Texas
| | - A. Dolly
- East Texas Medical Center, Department of Trauma, Tyler, Texas
| | - S. Norwood
- East Texas Medical Center, Department of Trauma, Tyler, Texas
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