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Bayuo J, Baffour PK. Utilisation of palliative/ end-of-life care practice recommendations in the burn intensive care unit of a Ghanaian tertiary healthcare facility: An observational study. Burns 2024; 50:1632-1639. [PMID: 38582696 DOI: 10.1016/j.burns.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The need to integrate palliative/end-of-life care across healthcare systems is critical considering the increasing prevalence of health-related suffering. In burn care, however, a general lack of practice recommendations persists. Our burn unit developed practice recommendations to be implemented and this study aimed to examine the components of the practice recommendations that were utilised and aspects that were not to guide further training and collaborative efforts. METHODS We employed a prospective clinical observation approach and chart review to ascertain the utilisation of the recommendations over a 3-year period for all burn patients. We formulated a set of trigger parametres based on existing literature and burn care staff consultation in our unit. Additionally, a checklist based on the practice recommendations was created to record the observations and chart review findings. All records were entered into a secure form on Google Forms following which we employed descriptive statistics in the form of counts and percentages to analyse the data. RESULTS Of the 170 burn patients admitted, 66 (39%) persons died. Although several aspects of each practice recommendation were observed, post-bereavement support and collaboration across teams are still limited. Additionally, though the practice recommendations were comprehensive to support holistic care, a preponderance of delivering physical care was noted. The components of the practice recommendations that were not utilised include undertaking comprehensive assessment to identify and resolve patient needs (such as spiritual and psychosocial needs), supporting family members across the injury trajectory, involvement of a palliative care team member, and post-bereavement support for family members, and burn care staff. The components that were not utilised could have undoubtedly helped to achieve a comprehensive approach to care with greater family and palliative care input. CONCLUSION We find a great need to equip burn care staff with general palliative care skills. Also, ongoing collaboration/ partnership between the burn care and palliative care teams need to be strengthened. Active family engagement, identifying, and resolving other patient needs beyond the physical aspect also needs further attention to ensure a comprehensive approach to end of life care in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing and Midwifery, Presbyterian University, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
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Harrison BH, DeGennaro R, Wiencek C. Innovative Strategies for Palliative Care in the Intensive Care Unit. AACN Adv Crit Care 2024; 35:157-167. [PMID: 38848573 DOI: 10.4037/aacnacc2024761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.
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Affiliation(s)
- Brittany H Harrison
- Brittany H. Harrison is Nurse Practitioner, University of Virginia (UVA) Health, 1215 Lee St, Charlottesville, VA 22901
| | - Regina DeGennaro
- Regina DeGennaro is Professor of Nursing, UVA School of Nursing, Charlottesville, Virginia
| | - Clareen Wiencek
- Clareen Wiencek is Professor of Nursing, UVA School of Nursing, Charlottesville, Virginia
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Bayuo J, Kyei Baffour P. Healthcare Staff Perceptions Regarding Barriers and Enablers to End-of-Life Care Provision in Non-Palliative Care Settings in Ghana: A Multicentre Qualitative Study. OMEGA-JOURNAL OF DEATH AND DYING 2024; 89:259-274. [PMID: 35090354 DOI: 10.1177/00302228211072970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The projected rise in health-related suffering warrants the integration of palliative care across all health systems. For traditionally non-palliative care settings, barriers and enablers to palliative care integration remain poorly understood. This study sought to explore these barriers and enablers in the Emergency and Burn Units across two healthcare facilities in the middle belt of Ghana using qualitative description. Thirty-nine healthcare staff comprising 20 burn care staff and 19 ED staff were purposively recruited and interviewed. Interviews were transcribed following which thematic analysis was performed inductively. Two themes and six subthemes emerged from the data. The Ghanaian socio-cultural context often crippled the discussion of death and dying. Overall, there is a perceived tension between emergency/burns and end-of-life care. Opportunities however exist to improve the situation which will require more work regarding curricula improvement, providing avenues for professional development, culturally sensitive communication, and identifying strategies of engaging relatives.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
- Department of Nursing, Presbyterian University College, Ghana
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Almalki N, Boyle B, O'Halloran P. What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review. BMC Palliat Care 2024; 23:87. [PMID: 38556888 PMCID: PMC10983740 DOI: 10.1186/s12904-024-01413-7] [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: 11/16/2023] [Accepted: 03/17/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?' METHODS The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period. RESULTS We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment. CONCLUSIONS This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.
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Affiliation(s)
- Nabat Almalki
- Prince Sultan Military College for Health Sciences, Dharan, Saudi Arabia.
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Breidge Boyle
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
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Taqi KM, Lee CW, Zhang JW, Hawley P, Cheifetz R. Practicing Surgeons' Perception of Barriers to Palliative Care Delivery in British Columbia. Cureus 2024; 16:e58061. [PMID: 38738150 PMCID: PMC11088467 DOI: 10.7759/cureus.58061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Utilization of palliative care remains low among surgical patients. We aim to characterize general surgeons' perceptions of barriers to access palliative care in British Columbia (BC). METHODS Semi-structured interviews were carried out with a total of 11 surgeons in BC. Interviews were transcribed for thematic analysis via interpretive description. Dominant themes were identified and agreed upon between the authors. RESULTS Several barriers were identified, which include system and institution, communication and surgical workflow barriers. At the system and institutional level, there were difficulties accessing patient information and continuity of care. Themes in the communication included patient misconceptions about palliative care and communication challenges with consulting services. Surgical workflow barriers influenced the overall perceived role of surgeons when caring for patients with palliative care needs. CONCLUSION Understanding surgeons' perspectives on barriers to palliative care is an important step in changing management. This can aid in the development of strategies that ease access to palliative care.
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Affiliation(s)
- Kadhim M Taqi
- Department of Surgery, University of British Columbia, Vancouver, CAN
| | - Christina W Lee
- Department of Surgery, University of British Columbia, Vancouver, CAN
| | - Jenny W Zhang
- Department of Surgery, University of British Columbia, Vancouver, CAN
| | - Philippa Hawley
- Department of Medicine, University of British Columbia, Vancouver, CAN
| | - Rona Cheifetz
- Department of Surgery, University of British Columbia, Vancouver, CAN
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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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Lin J, Cook M, Siegel T, Marterre B, Chapman AC. Time is Short: Tools to Integrate Palliative Care and Communication Skills Education into Your Surgical Residency. JOURNAL OF SURGICAL EDUCATION 2023; 80:1669-1674. [PMID: 37385930 DOI: 10.1016/j.jsurg.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
The need to integrate palliative care (PC) training into surgical education has been increasingly recognized. Our aim is to describe a set of PC educational strategies, with a range of requisite resources, time, and prior expertise, to provide options that surgical educators can tailor for different programs. Each of these strategies has been successfully employed individually or in some combination at our institutions, and components can be generalized to other training programs. Asynchronous and individually paced PC training can be provided using existing resources published by the American College of Surgeons and upcoming SCORE curriculum modules. A multiyear PC curriculum, with didactic components of increasing complexity for more advanced residents, can be applied based on available time in the didactic schedule and local expertise. Simulation-based training in PC skills can be developed to provide objective competency-based training. Finally, a dedicated rotation on a surgical palliative care service can provide the most immersive experience with steps toward clinical entrustment of PC skills for trainees.
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Affiliation(s)
- Joseph Lin
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Buddy Marterre
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Section of Gerontology and Geriatric Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Allyson Cook Chapman
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California.
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Bayuo J, Abu-Odah H, Koduah AO. Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review. J Palliat Care 2023; 38:239-253. [PMID: 35603876 DOI: 10.1177/08258597221102735] [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
Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
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Sasnal M, Lorenz KA, McCaa M, Wu A, Morris AM, Schenker Y, Shreve ST, Giannitrapani KF. "It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period. J Pain Symptom Manage 2023; 65:263-272. [PMID: 36646332 DOI: 10.1016/j.jpainsymman.2022.12.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023]
Abstract
CONTEXT Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear. OBJECTIVES To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period. METHODS This cross-sectional multiphase qualitative study included 23 semistructured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review (Krippendorf α above 0.8). RESULTS Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: 1) mutual trust; 2) mutual respect; 3) perceived usefulness; 4) shared clinical objectives; 5) effective communication; and 6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: 1) being present, available, and responsive; 2) understanding roles; 3) establishing communication; 4) recognizing an intermediary and connecting role of supporting team members; 5) working as a team; and 6) building on previous experiences. CONCLUSION The study informs future interventions to improve the quality of care for seriously ill patients by better-involving PC in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.
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Affiliation(s)
- Marzena Sasnal
- Stanford Medicine, Surgery Policy Improvement Research & Education Center (M.S., A.M.M.), Stanford California, USA
| | - Karl A Lorenz
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA; Stanford Medicine, Primary Care and Population Health (K.A.L., K.F.G.), Stanford, California, USA
| | - Matthew McCaa
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA
| | - Adela Wu
- Department of Neurosurgery, Stanford Medicine (A.W.), Stanford, California, USA
| | - Arden M Morris
- Stanford Medicine, Surgery Policy Improvement Research & Education Center (M.S., A.M.M.), Stanford California, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh (Y.S.), Pittsburgh, Pennsylvania, USA
| | - Scott T Shreve
- United States Department of Veterans Affairs, VA Palliative Care (S.T.S.), Lebanon, Pennsylvania, USA
| | - Karleen F Giannitrapani
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA; Stanford Medicine, Primary Care and Population Health (K.A.L., K.F.G.), Stanford, California, USA.
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Cook MR, Schultz Reed K, Crannell WC, Brasel KJ, Siegel TR. Integrating Surgical Palliative Care Into the Full Spectrum of Medical Education. Am Surg 2023:31348231157418. [PMID: 36793013 DOI: 10.1177/00031348231157418] [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: 02/17/2023]
Abstract
We describe our institutional approach to incorporating surgical palliative care education into the Undergraduate Medical Education, Graduate Medical Education and Continuing Medical Education spaces as a model to help guide similarly interested educators. We had a well-established Ethics and Professionalism Curriculum, but an educational needs assessment revealed that both the residents and faculty felt that additional training in palliative care principles was crucial. We describe our full spectrum palliative care curriculum, which begins with the medical students on their surgical clerkship and continues with a 4 week surgical palliative care rotation for categorical general surgery PGY-1 residents, as well as a Mastering Tough Conversations course over several months at the end of the first year. Surgical Critical Care rotations, Intensive Care Unit debriefs after major complications, deaths, and other high-stress events are described, as is the CME domain, which includes routine Department of Surgery Death Rounds and a focus on palliative care concepts in Departmental Morbidity and Mortality conference. The Peer Support program and Surgical Palliative Care Journal Club round out our current educational endeavor. We describe our plans to create a full spectrum surgical palliative care curriculum that is fully integrated with the 5 clinical years of surgical residency, and include our proposed educational goals and year-specific objectives. The development of a Surgical Palliative Care Service is also described.
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Affiliation(s)
- Mackenzie R Cook
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | - Kristen Schultz Reed
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | | | - Karen J Brasel
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | - Timothy R Siegel
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
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Schultz K, Howard S, Moreno K, Siegel T, Zonies D, Brasel K, Cook M. What Should the Surgeons Do at the Family Meeting: A Multi-Disciplinary Qualitative Description of Surgeon Participation in Palliative Care Discussions. JOURNAL OF SURGICAL EDUCATION 2023; 80:110-118. [PMID: 36089480 DOI: 10.1016/j.jsurg.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/12/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE National guidelines have suggested that quality surgical care should incorporate effective palliative care (PC). Numerous barriers to surgeon participation remain and the domains of optimal surgeon participation are unclear. DESIGN Eight semi-structured and multi-professional focus groups with 34 total participants. Discussion was transcribed, and qualitative approaches were used to encode, identify, and categorize emergent themes. SETTING Oregon Health & Science University, Portland Oregon. A tertiary care teaching hospital. PARTICIPANTS 34 multi-disciplinary participants in eight focus groups, identified on a volunteer basis. RESULTS Key themes defining domains of optimal surgeon/palliative practice include: (1) "primary/secondary PC" which detailed conflict between the surgeon's desire to be part of palliative discussions and competing clinical/time demands. (2) "role/responsibility" described the tension surgeons feel around a desire to provide honest and goal concordant care (3) "teamwork/conflict" detailed the approach to disagreement among multidisciplinary teams. CONCLUSIONS In this qualitative analysis, emergent themes suggest that surgeons want to be involved in the PC of their patients but are limited by available time and competing for ethical obligations. Tension between competing communication and care obligations and PC goals is common, and discord around patient goals remains an issue. This work highlights the need for a standardized curriculum to improve the PC of surgical patients.
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Affiliation(s)
- Kristen Schultz
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Shannon Howard
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kirstin Moreno
- Office of Educational Improvement Innovation, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Medicine, Division of Hematology/Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karen Brasel
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Mackenzie Cook
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon.
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Gupta N, Gupta R, Gupta A. Rationale for integration of palliative care in the medical intensive care: A narrative literature review. World J Crit Care Med 2022; 11:342-348. [PMID: 36439323 PMCID: PMC9693909 DOI: 10.5492/wjccm.v11.i6.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/01/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.
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Affiliation(s)
- Nishkarsh Gupta
- Department of Anesthesiology, All India Institute of Medical Sciences, Delhi 110029, India
| | - Raghav Gupta
- Department of Onco-Anesthesiology and Palliative Medicine, All India Institute of Medical Sciences, Delhi 110029, India
| | - Anju Gupta
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi 110029, India
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Chapman AC, Lin JA, Cobert J, Marks A, Lin J, O'Riordan DL, Pantilat SZ. Utilization and Delivery of Specialty Palliative Care in the ICU: Insights from the Palliative Care Quality Network. J Pain Symptom Manage 2022; 63:e611-e619. [PMID: 35595374 PMCID: PMC9303815 DOI: 10.1016/j.jpainsymman.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Palliative care (PC) benefits critically ill patients but remains underutilized. Important to developing interventions to overcome barriers to PC in the ICU and address PC needs of ICU patients is to understand how, when, and for which patients PC is provided in the ICU. OBJECTIVES Compare characteristics of specialty PC consultations in the ICU to those on medical-surgical wards. METHODS Retrospective analysis of national Palliative Care Quality Network data for hospitalized patients receiving specialty PC consultation January 1, 2013 to December 31, 2019 in ICU or medical-surgical setting. 98 inpatient PC teams in 16 states contributed data. Measures and outcomes included patient characteristics, consultation features, process metrics and patient outcomes. Mixed effects multivariable logistic regression was used to compare ICU and medical-surgical units. RESULTS Of 102,597 patients 63,082 were in medical-surgical units and 39,515 ICU. ICU patients were younger and more likely to have non-cancer diagnoses (all P < 0.001). While fewer ICU patients were able to report symptoms, most patients in both groups reported improved symptoms. ICU patients were more likely to have consultation requests for GOC, comfort care, and withdrawal of interventions and less likely for pain and/or symptoms (OR-all P < 0.001). ICU patients were less often discharged alive. CONCLUSION ICU patients receiving PC consultation are more likely to have non-cancer diagnoses and less likely able to communicate. Although symptom management and GOC are standard parts of ICU care, specialty PC in the ICU is often engaged for these issues and results in improved symptoms, suggesting routine interventions and consultation targeting these needs could improve care.
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Affiliation(s)
- Allyson Cook Chapman
- Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, California; Critical Care Medicine, Department of Anesthesia (A.C.C., J.C.), University of California San Francisco, San Francisco, California.
| | - Joseph A Lin
- Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, California
| | - Julien Cobert
- Anesthesia Service (J.C.), San Francisco VA Health Care System, San Francisco, California; Critical Care Medicine, Department of Anesthesia (A.C.C., J.C.), University of California San Francisco, San Francisco, California
| | - Angela Marks
- Department of Medicine (A.M.), University of California San Francisco, San Francisco, California
| | - Jessica Lin
- Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
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14
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THE SPECIALTY OF SURGICAL CRITICAL CARE: A WHITE PAPER FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA CRITICAL CARE COMMITTEE. J Trauma Acute Care Surg 2022; 93:e80-e88. [PMID: 35319544 DOI: 10.1097/ta.0000000000003629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Keon-Cohen ZM, Story DA, Moran JA, Jones DA. An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals. Anaesth Intensive Care 2022; 50:234-242. [PMID: 35301860 DOI: 10.1177/0310057x211032652] [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
The number of older, frail patients undergoing surgery is increasing, prompting consideration of the benefits of intensive treatment. Despite collaborative decision-making processes such as advance care planning being supported by recent Australian legislation, their role in perioperative care is yet to be defined. Furthermore, there has been little evaluation of the quality of end-of-life care in the surgical population. We investigated documentation of the premorbid functional status, severity of illness, intensity of treatment, operative management and quality of end-of-life care in patients who died in a surgical unit, with a retrospective study of surgical mortality which was performed across three hospitals over a 23-month period in Victoria, Australia. Among 99 deceased patients in the study cohort, 68 had a surgical operation. Preoperative functional risk assessment by medical staff was infrequently documented in the medical notes (5%) compared with activities of daily living (69%) documented by nursing staff. Documented preoperative discussions regarding the risk of death were rarely and inconsistently done, but when done were extensive. Documented end-of-life care discussions were identified in 71%, but were frequently brief, inconsistent, and in 60% did not occur until 48 hours from death. In 35.4% of instances, documented discussions involved junior staff (registrars or residents), and 43.4% involved intensive care unit staff. Palliative or terminal care referrals also occurred late (1-2 days prior to death). Not-for-resuscitation orders were frequently changed when approaching the end of life. Overall, 57% of deceased patients had a documented opportunity for farewell with family. We conclude that discussions and documentation of end-of-life care practices could be improved and recommend that all surgical units undertake similar audits to ensure that end-of-life care discussions occur for high-risk and palliative care surgical patients and are documented appropriately.
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Affiliation(s)
- Zoe M Keon-Cohen
- Department of Anaesthesia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.,Anaesthesia Department, Austin Health, Australia
| | - David A Story
- Anaesthesia Department, Austin Health, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Juli A Moran
- Department of Palliative Care, 3805Austin Health, Austin Health, Australia
| | - Daryl A Jones
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.,Intensive Care Unit, Austin Health, Australia
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16
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Cralley A, Madsen H, Robinson C, Platnick C, Madison S, Trabert T, Cohen M, Cothren Burlew C, Sauaia A, Platnick KB. Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model. J Palliat Care 2022; 37:562-569. [PMID: 35138198 DOI: 10.1177/08258597221079438] [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
OBJECTIVE(S) Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. METHODS A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. RESULTS There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). CONCLUSIONS Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.
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Affiliation(s)
| | - Helen Madsen
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | | | | | - Angela Sauaia
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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17
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Schultz K, Howard S, Siegel T, Zonies D, Brasel K, Cook M, Moreno K. Supporting surgical residents learning clinical palliative care: Insights from multi-disciplinary focus groups. Am J Surg 2022; 224:676-680. [DOI: 10.1016/j.amjsurg.2022.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/26/2022] [Accepted: 02/25/2022] [Indexed: 12/18/2022]
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18
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Ferre AC, DeMario BS, Ho VP. Narrative review of palliative care in trauma and emergency general surgery. ANNALS OF PALLIATIVE MEDICINE 2022; 11:936-946. [PMID: 34551577 PMCID: PMC8901564 DOI: 10.21037/apm-20-2428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 08/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this article is to discuss the goals of palliative care with regards to acute care surgery patients and review the literature regarding administration and implementation of palliative programs. BACKGROUND For patients who experience unexpected and sometimes catastrophic life changes related to trauma or emergency general surgery, palliative care is a crucial adjunct that can help ensure the provision of optimal symptom management, communication, and goal-concordant care provided. METHODS Palliative care is medical specialty with a philosophy of care focused on improving the quality of life for patients with serious injury or illness and their loved ones. Palliative care provides significant benefit across the entire spectrum of illness and injury, regardless of prognosis. We will discuss palliative care topics related to trauma and emergency general surgery patients, including symptom management, goal setting, end of life care, communication strategies, addressing implicit/explicit bias, trauma-specific and emergency general surgery-specific considerations, and implementation strategies to reduce barriers for utilization of palliative care. CONCLUSIONS Unfortunately, palliative care is often underutilized in the trauma and emergency general surgery population. Acute care surgeons should be familiar with principles of primary palliative care, as well as understand the added benefits that be provided by consultant palliative care specialists.
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Affiliation(s)
- Alexandra C. Ferre
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA;,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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19
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Role of Palliative Care. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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20
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Hua M, Fonseca LD, Morrison RS, Wunsch H, Fullilove R, White DB. What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study. J Pain Symptom Manage 2021; 62:1273-1282. [PMID: 34182102 PMCID: PMC8648909 DOI: 10.1016/j.jpainsymman.2021.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable. OBJECTIVE To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases. METHODS Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison. RESULTS We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The "nascent" phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key "transitional" phase, use of specialists depended on development of "comfort and trust", which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the "mature" phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team. CONCLUSION This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
| | - Laura D Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; James J Peters VA, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fullilove
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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21
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Kanwar A, Patlolla SH, Singh M, Murphree DH, Sundaragiri PR, Jaber WA, Nicholson WJ, Vallabhajosyula S. Temporal Trends, Predictors and Outcomes of Inpatient Palliative Care Use in Cardiac Arrest Complicating Acute Myocardial Infarction. Resuscitation 2021; 170:53-62. [PMID: 34780813 DOI: 10.1016/j.resuscitation.2021.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Utilization of inpatient palliative care services (PCS) has been infrequently studied in patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). METHODS Adult AMI-CA admissions were identified from the National Inpatient Sample (2000-2017). Outcomes of interest included temporal trends and predictors of PCS use and in-hospital mortality, length of stay, hospitalization costs and discharge disposition in AMI-CA admissions with and without PCS use. Multivariable logistic regression and propensity matching were used to adjust for confounding. RESULTS Among 584,263 AMI-CA admissions, 26,919 (4.6%) received inpatient PCS. From 2000 to 2017 PCS use increased from <1% to 11.5%. AMI-CA admissions that received PCS were on average older, had greater comorbidity, higher rates of cardiogenic shock, acute organ failure, lower rates of coronary angiography (48.6% vs 63.3%), percutaneous coronary intervention (37.4% vs 46.9%), and coronary artery bypass grafting (all p < 0.001). Older age, greater comorbidity burden and acute non-cardiac organ failure were predictive of PCS use. In-hospital mortality was significantly higher in the PCS cohort (multivariable logistic regression: 84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; propensity-matched analysis: 84.7% vs. 66.2%, p < 0.001). The PCS cohort received a do- not-resuscitate status more often (47.6% vs. 3.7%), had shorter hospital stays (4 vs 5 days), and were discharged more frequently to skilled nursing facilities (73.6% vs. 20.4%); all p < 0.001. These results were consistent in the propensity-matched analysis. CONCLUSIONS Despite an increase in PCS use in AMI-CA, it remains significantly underutilized highlighting the role for further integrating of these specialists in AMI-CA care.
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Affiliation(s)
- Ardaas Kanwar
- University of Minnesota, Minneapolis, MN, United States
| | - Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Dennis H Murphree
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC, United States
| | - Wissam A Jaber
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - William J Nicholson
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States.
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22
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Lin JA, Im CJ, O'Sullivan P, Kirkwood KS, Cook AC. The surgical resident experience in serious illness communication: A qualitative needs assessment with proposed solutions. Am J Surg 2021; 222:1126-1130. [PMID: 34565516 PMCID: PMC9365675 DOI: 10.1016/j.amjsurg.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/04/2021] [Accepted: 09/13/2021] [Indexed: 11/21/2022]
Abstract
Background: Serious illness communication skills are important tools for surgeons, but training in residency is limited. Methods: Thirteen senior surgical residents at an academic center were interviewed about their experiences with serious illness communication. Conventional content analysis was performed using established communication frameworks and inductive development of themes. Results: Residents had frequent conversations and employed known communication strategies. Three themes highlighted challenges they face. Illness severity included factors attributed to the illness that made serious illness communication more challenging: symptoms, poor prognosis, and urgency. Knowledge and feelings included the factual understanding and emotional experience of residents, patients, and families. Academic structure included hierarchy and the residents’ dual role as learners and teachers. On reflection, residents identified needing greater experiential practice, analogous to learning procedural skills. Conclusions: Surgical residents regularly face serious illness conversations with little training beyond observation of role models. Dedicated training may help meet this need.
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Affiliation(s)
- Joseph A Lin
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Cecilia J Im
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Patricia O'Sullivan
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Allyson C Cook
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
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23
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Haines L, Wang W, Harhay M, Martin N, Halpern S, Courtright K. Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness. Am J Hosp Palliat Care 2021; 39:633-640. [PMID: 34467775 DOI: 10.1177/10499091211042303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. OBJECTIVE Describe patterns of PC delivery among a large, critically ill trauma cohort. SETTING/SUBJECTS Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. METHODS We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. RESULTS Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. CONCLUSION PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.
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Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael Harhay
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Niels Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Katherine Courtright
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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24
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Zimmermann CJ, Zelenski AB, Buffington A, Baggett ND, Tucholka JL, Weis HB, Marka N, Schoultz T, Kalbfell E, Campbell TC, Lin V, Lape D, Brasel KJ, Phelan HA, Schwarze ML. Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury. J Trauma Acute Care Surg 2021; 91:542-551. [PMID: 34039930 PMCID: PMC8939782 DOI: 10.1097/ta.0000000000003281] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND "Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients. METHODS We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress. RESULTS BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds. CONCLUSION BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
| | - Amy B. Zelenski
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - Anne Buffington
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nathan D. Baggett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jennifer L. Tucholka
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Holly B. Weis
- Department of Surgery, University of Texas Southwestern, Dallas TX
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Thomas Schoultz
- Department of Surgery, University of Texas Southwestern, Dallas TX
| | - Elle Kalbfell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Toby C. Campbell
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - Vivian Lin
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - Diane Lape
- Department of Surgery, Oregon Health and Science University, Portland OR
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland OR
| | | | - Margaret L. Schwarze
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medical History and Bioethics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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25
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma. Am J Surg 2021; 223:998-1003. [PMID: 34384589 PMCID: PMC8818056 DOI: 10.1016/j.amjsurg.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma. METHODS We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group. RESULTS Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days. CONCLUSIONS Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.
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Ho VP, Adams SD, O'Connell KM, Cocanour CS, Arbabi S, Powelson EB, Cooper Z, Stein DM. Making your geriatric and palliative programs a strength: TQIP guideline implementation and the VRC perspective. Trauma Surg Acute Care Open 2021; 6:e000677. [PMID: 34337156 PMCID: PMC8286789 DOI: 10.1136/tsaco-2021-000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/05/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Older patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program's best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification. METHODS We discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions. RESULTS We describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen. DISCUSSION Specialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V.
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Affiliation(s)
- Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | | | - Saman Arbabi
- Surgery, University of Washington, Seattle, Washington, USA
| | - Elisabeth B Powelson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Paré K, Grudziak J, Lavin K, Sten MB, Huegerich A, Umble K, Twer E, Reid T. Family Perceptions of Palliative Care and Communication in the Surgical Intensive Care Unit. J Patient Exp 2021; 8:23743735211033095. [PMID: 34345657 PMCID: PMC8283220 DOI: 10.1177/23743735211033095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Few data exist on palliative care for trauma and acute care surgery patients. This pilot study evaluated family perceptions and experiences around palliative care in a surgical intensive care unit (SICU) via mixed methods interviews conducted from February 1, 2020, to March 5, 2020, with 5 families of patients in the SICU. Families emphasized the importance of clear, honest communication, and inclusiveness in decision-making. Many interviewees were unable to recall whether goals-of-care discussions had occurred, and most lacked understanding of the patients' illnesses. This study highlights the significance of frequent communication and goals-of-care discussions in the SICU.
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Affiliation(s)
- Kristina Paré
- Gillings School of Public Health, The University of North Carolina, Chapel Hill, NC, USA
| | - Joanna Grudziak
- Department of Surgery, The University of North Carolina, Chapel Hill, NC, USA
| | - Kyle Lavin
- Palliative Care Program, The University of North Carolina, Chapel Hill, NC, USA
| | - May-Britt Sten
- Institute for Healthcare Quality Improvement, The University of North Carolina, Chapel Hill, NC, USA
| | - Anneka Huegerich
- Surgical Intensive Care Unit, The University of North Carolina, Chapel Hill, NC, USA
| | - Karl Umble
- Gillings School of Public Health, The University of North Carolina, Chapel Hill, NC, USA
| | - Emma Twer
- Department of Surgery, The University of North Carolina, Chapel Hill, NC, USA
| | - Trista Reid
- Gillings School of Public Health, The University of North Carolina, Chapel Hill, NC, USA.,Department of Surgery, The University of North Carolina, Chapel Hill, NC, USA
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Quelal K, Olagoke O, Shahi A, Torres A, Ezegwu O, Golzar Y. Trends and Predictors of Palliative Care Consultation Among Patients Admitted for LVAD: A Retrospective Analysis From the Nationwide Inpatient Sample Database From 2006-2014. Am J Hosp Palliat Care 2021; 39:353-360. [PMID: 34080439 DOI: 10.1177/10499091211021837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are an essential part of advanced heart failure (HF) management, either as a bridge to transplantation or destination therapy. Patients with advanced HF have a poor prognosis and may benefit from palliative care consultation (PCC). However, there is scarce data regarding the trends and predictors of PCC among patients undergoing LVAD implantation. AIM This study aims to assess the incidence, trends, and predictors of PCC in LVAD recipients using the United States Nationwide Inpatient Sample (NIS) database from 2006 until 2014. METHODS We conducted a weighted analysis on LVAD recipients during their index hospitalization. We compared those who had PCC with those who did not. We examined the trend in palliative care utilization and calculated adjusted odds ratios (aOR) to identify demographic, social, and hospital characteristics associated with PCC using multivariable logistic regression analysis. RESULTS We identified 20,675 admissions who had LVAD implantation, and of them 4% had PCC. PCC yearly rate increased from 0.6% to 7.2% (P < 0.001). DNR status (aOR 28.30), female sex (aOR 1.41), metastatic cancer (aOR: 3.53), Midwest location (aOR 1.33), and small-sized hospitals (aOR 2.52) were positive predictors for PCC along with in-hospital complications. Differently, Black (aOR 0.43) and Hispanic patients (aOR 0.25) were less likely to receive PCC. CONCLUSION There was an increasing trend for in-hospital PCC referral in LVAD admissions while the overall rate remained low. These findings suggest that integrative models to involve PCC early in advanced HF patients are needed to increase its generalized utilization.
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Affiliation(s)
- Karol Quelal
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Olankami Olagoke
- Division of Cardiovascular Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Anoj Shahi
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Andrea Torres
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Olisa Ezegwu
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Yasmeen Golzar
- Division of Cardiology, Cook County Health, Chicago, IL, USA
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Amen SS, Berndtson AE, Cain J, Onderdonk C, Cochran-Yu M, Gambles Farr S, Edwards SB. Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship. J Surg Res 2021; 266:236-244. [PMID: 34029763 DOI: 10.1016/j.jss.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/25/2021] [Accepted: 03/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation. METHODS The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows). RESULTS For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged. CONCLUSION Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.
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Affiliation(s)
- Sara S Amen
- Department Of Surgery, California University of Science and Medicine, Colton, California
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California
| | - Julia Cain
- Doris A. Howell Palliative Teams, University Of California - San Diego, San Diego, California
| | - Christopher Onderdonk
- Doris A. Howell Palliative Teams, University Of California - San Diego, San Diego, California
| | - Meghan Cochran-Yu
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California; Department Of Surgery, Loma Linda University School Of Medicine, Loma Linda, California
| | - Samantha Gambles Farr
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California
| | - Sara B Edwards
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California; Department Of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System and CECORC, Moreno Valley, California.
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Cushman T, Waisel DB, Treggiari MM. The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective. Anesth Analg 2021; 133:663-675. [PMID: 34014183 DOI: 10.1213/ane.0000000000005559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
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Affiliation(s)
- Tera Cushman
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - David B Waisel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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Scheinberg-Andrews C, Ganz FD. Israeli Nurses' Palliative Care Knowledge, Attitudes, Behaviors, and Practices. Oncol Nurs Forum 2021; 47:213-221. [PMID: 32078607 DOI: 10.1188/20.onf.213-221] [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
OBJECTIVES To describe and compare self-perceived end-of-life (EOL) knowledge, attitudes, behaviors, and practices of intensive care unit (ICU) nurses compared to oncology nurses. SAMPLE & SETTING 126 Israeli nurses (79 oncology nurses and 47 ICU nurses) who were members of the Israel Association of Cardiology and Critical Care Nurses and the Israeli Oncology Nurses Organization. METHODS & VARIABLES This cross-sectional study used an online survey to gather demographic information, clinical setting, and study measures (EOL knowledge, attitudes, behaviors, and practices). RESULTS Oncology nurses and ICU nurses showed moderate levels of self-perceived knowledge and attitudes toward palliative care; however, their self-reported behaviors were low. Oncology nurses scored slightly higher than ICU nurses on knowledge and attitudes but not behaviors, although the difference was not statistically significant. IMPLICATIONS FOR NURSING Contrary to the current authors' expectations, oncology nurses and ICU nurses have similar levels of knowledge, attitudes, and behaviors regarding palliative care. Nurses in both settings need to be better trained and empowered to provide such care.
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Wycech J, Fokin AA, Katz JK, Viitaniemi S, Menzione N, Puente I. Comparison of Geriatric Versus Non-geriatric Trauma Patients With Palliative Care Consultations. J Surg Res 2021; 264:149-157. [PMID: 33831601 DOI: 10.1016/j.jss.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative care in trauma patients is still evolving. The goal was to compare characteristics, outcomes, triggers and timing for palliative care consultations (PCC) in geriatric (≥65 y.o.) and non-geriatric trauma patients. MATERIALS AND METHODS Retrospective study included 432 patients from two level 1 trauma centers who received PCC between December 2012 and January 2019. Non-geriatric (n = 61) and geriatric (n = 371) groups were compared for: mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS), Do-Not-Resuscitate (DNR) orders, futile interventions (FI), duration of mechanical ventilation (DMV), ICU admissions, ICU and hospital lengths of stay (ICULOS; HLOS), timing to PCC, and mortality. Further propensity matching (PM) analysis compared 59 non-geriatric to 59 Geriatric patients matched by ISS, GCS, and DNR. RESULTS Geriatric patients were older (85.2 versus 49.7), with falls as predominant MOI. Non-geriatric patients comprised 14.1% of all patients with PCC and were more severely injured than Geriatrics: with statistically higher ISS (24.1 versus 18.5), lower RTS (5.4 versus 7.0), GCS (7.1 versus 11.5), with predominant MOI being traffic accidents, all P < 0.01. Non-Geriatrics had more ICU admissions (96.7% versus 88.1%), longer ICULOS (10.2 versus 4.7 days), DMV (11.1 versus 4.1 days), less DNR (57.4% versus 73.9%), higher in-hospital mortality (12.5% versus 2.6%), but double the time admission-PCC (11.3 versus 4.3 days) compared to Geriatrics, all P < 0.04. In PM comparison, despite same injury severity, Non-geriatrics had triple the time to PCC, five times the HLOS of geriatrics, and more FI (25.4% versus 3.4%), all P < 0.001. CONCLUSIONS PCC remains underutilized in non-geriatric trauma patients. Despite higher injury severity, non-geriatrics received more aggressive treatment, and had three times longer time to PCC, resulting in higher rate of FI than in Geriatrics.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida.
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Sari Viitaniemi
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Nicholas Menzione
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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Epstein CD, Ventura-DiPersia C. Instrument Development: Knowledge, Attitudes, and Confidence in Palliative Care Concepts Held by Trauma and Neuroscience Intensive Care Nurses. J Nurs Meas 2021; 29:140-152. [PMID: 33593986 DOI: 10.1891/jnm-d-19-00069] [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: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Unique pressures impact trauma intensive care unit (TICU) nurses in their provision of care for severely injured patients. When it becomes clinically obvious that these patients may not survive, TICU nurses must continue life-saving measures while at the same time consider a palliative care consultation. In order to facilitate this referral, TICU nurses need to have the appropriate knowledge, attitude, and confidence in doing so. The purpose of this study is to refine an instrument that aims to support this process. METHODS A convenience sample of 42 respondents completed the Knowledge, Attitudinal, and Experiential Survey on Advance Directive (KAESAD). RESULTS Domains with the highest Cronbach's alpha value were "professional attitudes" (α = .995) and "clinical experiences" (α = .999). CONCLUSIONS Reliability assessments suggest that most domains of the instrument have strong internal consistency, and with a larger sample size, future studies may elucidate how nurse educators can use this instrument to target areas for continuing education.
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Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice. Dimens Crit Care Nurs 2021; 39:219-235. [PMID: 32467406 DOI: 10.1097/dcc.0000000000000423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting. OBJECTIVES This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines. METHODS This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time. RESULTS Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285). CONCLUSION This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.
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A Hill S, Dawood A, Boland E, Leahy HE, Em Murtagh F. Palliative medicine in the intensive care unit: needs, delivery, quality. BMJ Support Palliat Care 2021; 12:38-41. [PMID: 33602723 DOI: 10.1136/bmjspcare-2020-002795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND 15%-20% of critical care patients die during their hospital admission. This service evaluation assesses quality of palliative care in intensive care units (ICUs) compared with national standards. METHODS Retrospective review of records for all patients who died in four ICUs (irrespective of treatment limitation) between 1 June and 31 July 2019. Descriptive statistics reported for patient characteristics, length of stay, admission route, identification triggers and palliative care delivery. RESULTS Forty-five patients died, two records were untraced, thus N=43. The dying process was recognised in 88% (n=38). Among those where dying was recognised (N=35), 97% (34) had documented family discussion before death, 9% (3) were offered religious/spiritual support, 11% (4) had review of hydration/nutrition and 6% (2) had documented preferred place of death. Prescription of symptom control medications was complete in 71% (25) opioids, 34% (12) haloperidol, 54% (19) midazolam and 43% (15) hyoscine. Combining five triggers-length of stay >10 days prior to ICU admission 7% (3), multiorgan failure ≥3 systems 33% (14), stage IV malignancy 5% (2), post-cardiac arrest 23% (10) and intracerebral haemorrhage requiring mechanical ventilation 12% (5)-identified 60% (26) of patients. Referral to the palliative care team was seen in 14% (5), and 8% (3) had specialist palliative care team review. CONCLUSIONS Recognition of dying was high but occurred close to death. Family discussions were frequent, but religious/spiritual needs, hydration/nutrition and anticipatory medications were less often considered. The ICUs delivered their own palliative care in conjunction with specialist palliative care input. Combining five triggers could increase identification of palliative care needs, but a larger study is needed.
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Affiliation(s)
- Stephanie A Hill
- Intensive Care Unit, Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, UK
| | - Abdul Dawood
- Intensive Care Unit, Hull University Teaching Hospitals NHS Trust, Hull, Kingston upon Hull, UK
| | - Elaine Boland
- Palliative Medicine, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Hannah E Leahy
- Palliative Medicine, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, University of Hull, Hull, Kingston upon Hull, UK
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McGraw C, Vogel R, Redmond D, Pekarek J, Tanner A, Lynch N, Bar-Or D. Comparing satisfaction of trauma patients 55 years or older to their caregivers during palliative care: Who faces the burden? J Trauma Acute Care Surg 2021; 90:305-312. [PMID: 33075029 DOI: 10.1097/ta.0000000000002983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Many studies report on the patient-caregiver relationship during palliative care (PC); however, this relationship has yet to be examined following traumatic injury. METHODS This prospective cohort study included trauma patients (≥55 years) and their primary caregivers admitted at two level I trauma centers for 2 years (November 2016 to November 2018), who received PC and who completed satisfaction surveys before discharge; surveys were analyzed by four domains: information giving, availability of care, physical care, and psychosocial care, and by PC assessments: consultations, prognostications, formal family meetings (FFMs), and advanced goals of care discussions. The primary outcome was the percentage of patients and caregivers who were satisfied (defined as ≥80%) and was analyzed using McNemar's test. Adjusted mixed models identified PC assessments that were associated with satisfaction scores ≥80% for patients and caregivers. RESULTS Of the 441-patient and 441-caregiver pairs, caregivers were significantly less satisfied than patients during prognostications (information giving, physical care), FFMs (information giving, physical care), and consultations (physical care), while caregivers were significantly more satisfied than patients during advanced goals of care discussions (availability of care, psychosocial care). After adjustment, significant predictors of caregiver satisfaction (≥80%) included longer patient hospital length of stay (>4 days), caring for a male patient (physical care, availability of care), higher caregiver age (≥55 years; availability of care), and higher patient age (≥65 years; psychosocial care). Conversely, all PC assessments decreased odds of satisfaction for caregivers in every domain except physical care. Significant predictors of higher patient satisfaction included FFMs (for every domain) and PC consultations (psychosocial care), and decreased odds included advanced goals of care discussions and prognostication assessments (information giving, psychosocial care). CONCLUSIONS Palliative care increased satisfaction of patients, especially family meetings and consultations, while assessments were predictive of lower caregiver satisfaction, suggesting that caregivers may be experiencing some of the patient burden. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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Affiliation(s)
- Constance McGraw
- From the Trauma Research Department (C.M., J.P., D.B.-O.) and Trauma Services Department (R.V.), St. Anthony Hospital, Lakewood; Trauma Research Department (C.M., D.R., D.B.-O.) and Trauma Services Department (A.T., N.L.), Penrose-St. Francis Hospital, Colorado Springs, Colorado
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Morris M, Mroz EL, Popescu C, Baron-Lee J, Busl KM. Palliative Care Services in the NeuroICU: Opportunities and Persisting Barriers. Am J Hosp Palliat Care 2021; 38:1342-1347. [PMID: 33433236 DOI: 10.1177/1049909120987215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND End-of-life (EOL) supportive care, including palliative and hospice services, is an area of increasing importance in critical care. Neurointensivists face unique challenges in providing timely supportive care to terminally ill patients expected to expire in the NeuroICU. OBJECTIVE This study explored the extent of effective utilization of, and recorded barriers to, palliative and hospice services in a dedicated 30-bed NeuroICU at a large academic medical center. DESIGN A retrospective chart review of patients who expired in the NeuroICU was conducted. The timeline from patient admission to arrival of palliative care services was traced. Qualitative review of chart notes was used to identify barriers to provision of palliative services. SETTING A total of 330 patients expired in the NeuroICU during the study period, including 176 from the neurology and 154 from the neurosurgical service. RESULTS Across services, 146 expired patients were never referred to palliative care or hospice services. Of those referred, over one-third were referred more than 4 days past admission to the NeuroICU. On average, patients were referred with less than 1 day before expiration. Common barriers to referral for supportive services were documented (e.g., patient expected to expire, family declined service). CONCLUSIONS Despite benefits of palliative care and an in-hospital hospice opportunity, we identified lack of referral, and particularly delays in referral to services as significant barriers. Our study highlights these as missed opportunities for patients and families to receive maximum benefits from these services. Future research should solidify triggers for EOL services in this setting.
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Affiliation(s)
- Michael Morris
- Department of Neurology, 3463University of Florida, Gainesville, FL, USA
| | - Emily L Mroz
- Department of Neurology, 3463University of Florida, Gainesville, FL, USA.,Department of Psychology, 3463University of Florida, Gainesville, FL, USA
| | - Cristina Popescu
- Department of Social and Public Health, 1354Ohio University, Athens, OH, USA
| | | | - Katharina M Busl
- Department of Neurology, 3463University of Florida, Gainesville, FL, USA.,Department of Neurosurgery, 3463University of Florida, Gainesville, FL, USA
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Baimas-George M, Yelverton S, Ross SW, Rozario N, Matthews BD, Reinke CE. Palliative Care in Emergency General Surgery Patients: Reduced Inpatient Mortality And Increased Discharge to Hospice. Am Surg 2020; 87:1087-1092. [PMID: 33316173 DOI: 10.1177/0003134820956942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Admissions due to emergency general surgery (EGS) are on the rise, and patients who undergo emergency surgery are at increased risk of mortality. We hypothesized that utilization of palliative care and discharge to hospice in the EGS population have increased over time and that this is associated with a decrease in inpatient mortality. METHODS Using the 2002-2011 nationwide inpatient sample and American Association for the Surgery of Trauma-defined EGS diagnosis codes, we identified patients ≥18 years old with an EGS admission. Demographics, hospitalization characteristics, mortality, use of palliative care services, and discharge to hospice were queried. All Patient Refined-Diagnosis Related Group risk of mortality was used to categorize those with an extreme likelihood of dying (ELD). Multivariable logistic regression was used to investigate the association between palliative care consult and discharge to hospice. RESULTS Of the included patients, 0.3% received palliative care and 0.2% were discharged to hospice. Over time, rates of palliative care and hospice discharge increased while inpatient mortality decreased. In the 4% of patients with ELD, 3% received palliative care, 5% were transitioned to hospice care, and 22% suffered inpatient mortality. Controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR = 1.78 all patients and OR = 2.04 for ELD). CONCLUSIONS Despite the known increased risks associated with emergency surgical diagnoses, palliative care services remain infrequently utilized in the EGS population. This may be an opportunity for lessening suffering, improving patient-concordant care and outcomes, and reducing nonbeneficial and unwanted care.
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Affiliation(s)
| | - Sam Yelverton
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel W Ross
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Nigel Rozario
- Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Brent D Matthews
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Caroline E Reinke
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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Lee JD, Jennerich AL, Engelberg RA, Downey L, Curtis JR, Khandelwal N. Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness. J Palliat Med 2020; 24:857-864. [PMID: 33156728 DOI: 10.1089/jpm.2020.0412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.
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Affiliation(s)
- Joshua D Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Improving quality in colon and rectal surgery through palliative care. SEMINARS IN COLON AND RECTAL SURGERY 2020; 31:100783. [PMID: 33041605 PMCID: PMC7531922 DOI: 10.1016/j.scrs.2020.100783] [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] [Indexed: 11/25/2022]
Abstract
Palliative care is a medical discipline that emphasizes quality of life and can be provided in parallel with recovery-directed treatments in colon and rectal surgery. Palliative care is receiving increasing attention and investigation for its potential to improve quality and outcomes for a wide spectrum of patients by benefiting symptom management, supporting complex health care decision making and facilitating care transitions. Primary palliative care refers to the application of palliative care principles by clinicians of all disciplines whereas specialty palliative care is a multidisciplinary approach and includes a clinician with advanced training and experience.
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Esquibel BM, Waller CJ, Borgert AJ, Kallies KJ, Harter TD, Cogbill TH. The role of palliative care in acute trauma: When is it appropriate? Am J Surg 2020; 220:1456-1461. [PMID: 33051066 DOI: 10.1016/j.amjsurg.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/21/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.
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Affiliation(s)
- Brendon M Esquibel
- General Surgery Residency, Department of Medical Education, Gundersen Health System, La Crosse, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Thomas D Harter
- Department of Bioethics and Humanities, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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Wycech J, Fokin AA, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation. J Palliat Med 2020; 24:705-711. [PMID: 32975481 DOI: 10.1089/jpm.2020.0218] [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: 11/12/2022] Open
Abstract
Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | | | - Susan Koff
- TrustBridge Health, West Palm Beach, Florida, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida, USA
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Chatterjee K, Harrington S, Sexton K, Goyal A, Robertson RD, Corwin HL. Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013). Jt Comm J Qual Patient Saf 2020; 46:493-500. [PMID: 32414575 DOI: 10.1016/j.jcjq.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours). METHODS National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS. RESULTS Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization. CONCLUSIONS Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.
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Calle MC, Pareja SL, Villa MM, Román-Calderón JP, Lemos M, Navarro S, Krikorian A. Interactions Between Intensive Care and Palliative Care Are Influenced by Training, Professionals' Perceptions and Institutional Barriers. J Palliat Care 2020; 37:545-551. [PMID: 32812496 DOI: 10.1177/0825859720951361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is growing interest in the use of a Palliative care approach in Intensive care. However, it tends to remain inconsistent, infrequent or non-existent, as does its acceptance by intensive care physicians. This study sought to explore the perceptions, level of knowledge, perceived barriers, and practices of physicians regarding palliative care practices (PC) in Intensive Care Units (ICU). METHODS Descriptive-correlational study. Participating physicians working in ICU in Colombia (n = 101) completed an ad hoc questionnaire that included subscales of perceptions, knowledge, perceived barriers, and PC practices in ICU. A Structural Equation Model (PLS-SEM) was used to examine the reciprocal relationships between the measured variables and those that could predict interaction practices between the 2 specialties. RESULTS First, results from the measurement model to examine the validity and reliability of the latent variables found (PC training, favorable perceptions about PC, institutional barriers, and ICU-PC interaction practices) and their indicators were obtained. Second, the structural model found that, a greater number of hours of PC training, a favorable perception of PC and a lower perception of institutional barriers are related to greater interaction between PC and ICU, particularly when emotional or family problems are detected. CONCLUSIONS PC-ICU interactions are influenced by training, a positive perception of PC and less perceived institutional barriers. An integrated ICU-PC model that strengthens the PC training of those who work in ICU and provides clearer guidelines for interaction practices, may help overcome perceived barriers and improve the perception of the potential impact of PC.
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Affiliation(s)
| | | | | | | | | | - Stella Navarro
- School of medicine, Universidad CES, Medellín, Colombia.,Clínica Universitaria Bolivariana, Medellín, Colombia
| | - Alicia Krikorian
- Pain and Palliative Care Group, School of Health Sciences, 28025Universidad Pontificia Bolivariana, Medellín, Colombia
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Vogel R, McGraw C, Redmond D, Bourg Retired P, Dreiman C, Tanner A, Lynch N, Bar-Or D. The ACS-TQIP palliative care guidelines at two level I trauma centres: a prospective study of patient and caregiver satisfaction. BMJ Support Palliat Care 2020; 12:e120-e128. [PMID: 32581006 DOI: 10.1136/bmjspcare-2020-002229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To measure trauma patient and caregiver satisfaction before and after implementation of standardised palliative care (PC) guidelines. METHODS Prospective pre-post study at two level-I trauma centres. PC satisfaction surveys were administered prior to discharge for consented trauma patients (Family Satisfaction with Advanced Cancer Scale, Patient (FAMCARE-P13) survey)≥55 years, and their caregivers (FAMCARE survey), from 1 November 2016 to 30 November 2018. Standardised PC guidelines were implemented January 2018 and included consultations, prognostication assessments, identification of proxies, review of advanced directives and do not resuscitate orders within 24 hours of admission, while advanced goals of care, formal family meetings and spiritual care support were recommended within 72 hours of admission. Generalised linear models were used to determine whether differences in patient or caregiver satisfaction existed pre versus post implementation. RESULTS There were 572 patients (299 pre; 273 post) and 595 caregivers (334 pre; 261 post) included. Overall patient satisfaction significantly increased post implementation (82.0 vs 86.0, p=0.001). After adjustment, the implementation of the guidelines was an independent predictor of higher overall patient satisfaction (least squares mean (LSM= (83.8% (95%CI 81.2%-86.5%) vs 80.3% (77.7%-82.9%), p=0.003)). Compared with preimplementation, patient satisfaction was significantly higher post implementation in the following domains: information giving (80.9 vs 85.5, p=0.001), followed by physical care (82.2 vs 86.0, p=0.002), availability of care (83.4 vs 86.8, p=0.007) and psychosocial care (84.7 vs 87.6, p=0.04). No significant differences in caregiver satisfaction were found before or after adjustment (LSMpre: 83.1% (95%CI 80.9%-85.3%) vs. post: 82.4% (80.3%-84.5%), p=0.56)) CONCLUSIONS: Our data suggest that the implementation of PC guidelines significantly improved patient satisfaction following traumatic injury, while maintaining robust caregiver satisfaction.
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Affiliation(s)
- Rebecca Vogel
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Constance McGraw
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA.,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Diane Redmond
- Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Pamela Bourg Retired
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Chester Dreiman
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Allen Tanner
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Neal Lynch
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA .,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
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Abstract
Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.
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Affiliation(s)
- Rita C. Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Bayuo J, Bristowe K, Harding R, Agyei FB, Agbeko AE, Agbenorku P, Baffour PK, Allotey G, Hoyte-Williams PE. The Role of Palliative Care in Burns: A Scoping Review. J Pain Symptom Manage 2020; 59:1089-1108. [PMID: 31733355 DOI: 10.1016/j.jpainsymman.2019.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear. OBJECTIVE To appraise the literature on the role of palliative care in burns management. METHODS We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement. FINDINGS 39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines. CONCLUSION Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana
| | | | - Pius Agbenorku
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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50
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Abstract
OBJECTIVES Describe pediatric palliative care consult in children with heart disease; retrospectively apply Center to Advance Palliative Care criteria for pediatric palliative care consults; determine the impact of pediatric palliative care on end of life. DESIGN A retrospective single-center study. SETTING A 16-bed cardiac ICU in a university-affiliated tertiary care children's hospital. PATIENTS Children (0-21 yr old) with heart disease admitted to the cardiac ICU from January 2014 to June 2017. MEASUREMENTS AND MAIN RESULTS Over 1,000 patients (n = 1, 389) were admitted to the cardiac ICU with 112 (8%) receiving a pediatric palliative care consultation. Patients who received a consult were different from those who did not. Patients who received pediatric palliative care were younger at first hospital admission (median 63 vs 239 d; p = 0.003), had a higher median number of complex chronic conditions at the end of first hospitalization (3 vs 1; p < 0.001), longer cumulative length of stay in the cardiac ICU (11 vs 2 d; p < 0.001) and hospital (60 vs 7 d; p < 0.001), and higher mortality rates (38% vs 3%; p < 0.001). When comparing location and modes of death, patients who received pediatric palliative care were more likely to die at home (24% vs 2%; p = 0.02) and had more comfort care at the end of life (36% vs 2%; p = 0.002) compared to those who did not. The Center to Advance Palliative Care guidelines identified 158 patients who were eligible for pediatric palliative care consultation; however, only 30 patients (19%) in our sample received a consult. CONCLUSIONS Pediatric palliative care consult rarely occurred in the cardiac ICU. Patients who received a consult were medically complex and experienced high mortality. Comfort care at the end of life and death at home was more common when pediatric palliative care was consulted. Missed referrals were apparent when Center to Advance Palliative Care criteria were retrospectively applied.
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