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Wen FH, Prigerson HG, Chuang LP, Chou WC, Huang CC, Hu TH, Tang ST. Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms. Crit Care Med 2024:00003246-990000000-00372. [PMID: 39258967 DOI: 10.1097/ccm.0000000000006416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
OBJECTIVES Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability. DESIGN Prospective cohort study. SETTING Medical ICUs of two Taiwanese medical centers. SUBJECTS Two hundred eighty-eight family surrogates. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss. CONCLUSIONS Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taiwan, ROC
| | | | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
- College of Medicine, School of Medicine, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
- Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, ROC
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan, ROC
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Nguyen NV, Guillen Lozoya AH, Caruso MA, Capetillo Porraz MGD, Pacheco-Spann LM, Allyse MA, Barwise AK. Through the eyes of Spanish-speaking patients, caregivers, and community leaders: a qualitative study on the in-patient hospital experience. Int J Equity Health 2024; 23:164. [PMID: 39164755 PMCID: PMC11337574 DOI: 10.1186/s12939-024-02246-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 08/05/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND Spanish-speakers with non-English language preference and complex medical needs suffer disparities in quality of care, safety, and health outcomes. Communication challenges during prolonged hospitalizations for complex illnesses negatively influence how this group engages in their care and decision-making while hospitalized. Limited literature capturing the perspectives of Spanish-speaking patients in this context exists. Given the impact of language barriers on care and medical decision-making, this study documents the experiences of Spanish-speaking patients with NELP and hospitalized with complex care needs as well as caregivers and community leaders. METHODS Using community-engaged recruitment strategies and semi-structured interviews and a focus group, we gathered insights from Spanish-speaking patients hospitalized for prolonged periods, caregivers, and community leaders from three geographic regions. Data were deidentified, transcribed, translated, coded in duplicate, and analyzed guided by grounded theory using NVivo. RESULTS We interviewed 40 participants: 27 patients, 10 caregivers and 3 community leaders. We identified four major themes: (1) Disconnected experiences impeding interactions, communication, and decision-making (2) Inadequate interpreter services (3) Benefits and consequences of family at the bedside (4) Community -informed recommendations. CONCLUSION The study showed that in-person interpreters were preferred to virtual interpreters; yet interpreter access was suboptimal. This resulted in ad hoc family interpretation. Participants noted language negatively impacted patient's hospital experience, including decreasing confidence in medical decision-making. Recommendations from patients, caregivers, and community leaders included expanding interpreter access, bolstering interpreter quality and accuracy, and increasing resources for patient education.
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Affiliation(s)
| | | | - Maria A Caruso
- Community Based Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Laura M Pacheco-Spann
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
- Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Megan A Allyse
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
- Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Amelia K Barwise
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Schaefer SL, Thompson CH, Gluck S, Booth AEC, Dignam CM. A Retrospective Analysis of Characteristics Favouring In-Hospital Resuscitation Plan Completion, Their Timing, and Associated Outcomes. J Clin Med 2024; 13:4098. [PMID: 39064138 PMCID: PMC11277889 DOI: 10.3390/jcm13144098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups.
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Affiliation(s)
- Sara L. Schaefer
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Campbell H. Thompson
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Samuel Gluck
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Northern Adelaide Local Health Network, Adelaide, SA 5092, Australia
| | - Andrew E. C. Booth
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Colette M. Dignam
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
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4
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Hu Y, Wang W, Jiang Y, Wang X, Peng X, Xin M, Zhao J. Factors associated with family decision-making self-efficacy among family members of patients with advanced cancer in mainland China. Palliat Support Care 2024:1-7. [PMID: 38736428 DOI: 10.1017/s1478951524000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
OBJECTIVES In Chinese culture, family members are the main decision maker on end-of-life (EoL) issues for patients with advanced cancer. Yet little is known about Chinese families' confidence in making EoL decisions and its associated factors. This study aims to investigate the status and associated factors of Chinese family members' confidence in making EoL decisions for patients with advanced cancer. METHODS This cross-sectional study used a convenience sample of 147 family members of patients with stage III or stage IV cancer from a tertiary cancer center in Guangzhou, China. The questionnaires included demographic information of patients and their family members, patients' EoL preferences, and the Chinese version of the Family Decision-Making Self-Efficacy (FDMSE) Scale. RESULTS A total of145 family members (98.64%) completed the questionnaires. The average score of FDMSE was 3.92 ± 0.53. A multiple regression analysis showed that the factors associated with FDMSE included patients' duration of disease, health insurance, participation in EoL decision-making, the expression of unfilled wishes, and family members' employment status. SIGNIFICANCE OF RESULTS Chinese family members were not confident enough in making EoL decisions for patients with advanced cancer. It is recommended to develop cultural-tailored advanced care planning models to clarify patient preferences and to enhance the family members' self-efficacy in making EoL decisions with or for patients with advanced cancer.
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Affiliation(s)
- Yangfan Hu
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Wenxia Wang
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Yali Jiang
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Xixi Wang
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Xuelan Peng
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Mingzhu Xin
- Nursing Department, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Juanjuan Zhao
- School of Nursing, Sun Yat-sen University, Guangzhou, China
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Zahuranec DB, Ortiz C, Lank RJ, Zhang G, Shi X, Case E, Morgenstern LB. Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project. Stroke 2024; 55:678-686. [PMID: 38214155 PMCID: PMC10922558 DOI: 10.1161/strokeaha.123.043947] [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: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project. METHODS Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders. RESULTS Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, -0.17 to 1.12]; P=0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04-2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity (P=0.04), suggesting that this difference was primarily in older patients. CONCLUSIONS Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.
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Affiliation(s)
| | - Carmen Ortiz
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
| | - Rebecca J. Lank
- University of Iowa Carver College of Medicine, Iowa City, USA
| | - Guanghao Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
| | - Lewis B. Morgenstern
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
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Zheng Y, Zhang L, Ma S, Wu B, Chen P, Xu Y, Tan W, Li H, Wu Q, Zheng J. Care intervention on psychological outcomes among patients admitted to intensive care unit: an umbrella review of systematic reviews and meta-analyses. Syst Rev 2023; 12:237. [PMID: 38098025 PMCID: PMC10720116 DOI: 10.1186/s13643-023-02372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Numerous studies have explored care interventions to improve the psychological outcome of intensive care unit (ICU) patients, but inconclusive evidence makes it difficult for decision-makers, managers, and clinicians to get familiar with all available literature and find appropriate interventions. This umbrella review aimed to analyze the relationship between care intervention and psychological outcomes of ICU patients based on existing systematic reviews. METHODS An umbrella review of evidence across systematic reviews and meta-analyses published between 1987 and 2023 was undertaken. We systematically searched reviews that examined the association between care intervention and the improvement of adverse psychological outcomes in ICU patients using PubMed, EMBASE, Web of Science, Cochrane Library, and manual reference screening. The measurement tool (AMSTAR 2) was applied to evaluate the methodological quality of included studies. The excess significance bias, between-study heterogeneity expressed by I2, small-study effect, and evidence class were estimated. RESULTS A total of 5110 articles were initially identified from the search databases and nine of them were included in the analysis. By applying standardized criteria, only weak evidence was observed in 13 associations, even though most included reviews were of moderate to high methodological quality. These associations pertained to eight interventions (music therapy, early rehabilitation, post-ICU follow-up, ICU diary, information intervention, preoperative education, communication and psychological support, surrogate decision-making) and five psychological outcomes (post-intensive care syndrome, transfer anxiety, post-traumatic stress disorder, anxiety, and depression). Weak or null association was shown among the rest of the associations (e.g., weak association between music therapy and maternal anxiety or stress level). CONCLUSIONS The evidence of these eight supporting interventions to improve the adverse psychological outcomes of ICU patients and caregivers was weak. Data from more and better-designed studies with larger sample sizes are needed to establish robust evidence.
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Affiliation(s)
- Yafang Zheng
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Lijuan Zhang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Shihong Ma
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Bian Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Peipei Chen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Yan Xu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Wenting Tan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Hanzhan Li
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China
| | - Qiaomei Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China.
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China.
| | - Jingxia Zheng
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China.
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, People's Republic of China.
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Rei KM, Reddy V, Brazdzionis J, Siddiqi J. Determinants and Disparities of Neurosurgery Patients Refusing Inpatient Palliative Care After Provider Recommendation. Cureus 2023; 15:e49925. [PMID: 38179361 PMCID: PMC10765216 DOI: 10.7759/cureus.49925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Background Disparities have been found in the utilization of palliative care (PC). However, a limitation of existing research is that it co-mingles factors affecting whether a patient is offered PC with factors affecting whether a patient accepts/refuses PC. Our objective is to identify the determinants and disparities of neurosurgery patients accepting/refusing inpatient PC after a provider recommends an inpatient PC consult. Methodology In this single-center retrospective cohort study, the last 750 consecutive neurosurgery patient medical records were screened. Inclusion criteria were as follows: (1) the patient was seen by the neurosurgery service during their hospitalization and (2) the patient had a documented inpatient PC consult ordered or the patient had at least one progress note documenting PC in the plan of care. Excluded were patients not seen by the neurosurgery service during the hospitalization in which the PC consult order or plan was documented. Analysis was performed using multivariate logistic regression with backward stepwise variable selection. Candidate variables included age, gender, race, ethnicity, language, marital status, insurance type, surrogate decision-maker (SDM) relationship to patient, advanced directive, Charlson Comorbidity Index (CCI), ambulation, activities of daily living (ADL) dependence, primary diagnosis category, Glasgow Coma Scale (GCS) at the time of admission, GCS at the time of PC consult, GCS at the time of discharge, duration of hospitalization, and hospitalization mortality. Results Of the last 750 neurosurgery patients, this study included 144 patients (33.3% female; mean age 57.53±19.89 years). Among these patients, 109 patients (75.7%) accepted PC and 35 patients (24.3%) refused PC. Univariate analysis showed that patients refusing PC tended to be older (p=0.003) and have a shorter duration of hospitalization (p=0.023). Chi-squared analysis found associations between PC acceptance/refusal and preferred language (p=0.026), religion (p<0.001), and SDM relationship to patient (p=0.004). Multivariate logistic regression found that predictors of PC refusal were older age (OR=0.965, p=0.049), non-English (OR=0.219, p=0.004), adult child SDM (OR=0.246, p=0.023), and other relative/friend SDM (OR=0.208, p=0.011). Religious patients were more likely to accept PC (OR=7.132, p<0.001). Race and ethnicity factors were not found to be significant predictors of PC refusal: Black (p=0.649), other race (p=0.189), and Hispanic (p=0.525). Conclusion Nearly one-quarter of neurosurgery patients offered PC refused this care. Predictors of PC refusal were older age, non-English, adult child SDM, and other relative/friend SDM. Religious patients were more likely to accept PC. Race and ethnicity were not found to be significant predictors of accepting/refusing PC, which may suggest these previously identified disparities stem from minority patients being offered less PC. Additional research is needed to replicate these findings among different patient populations. Because PC is compatible with life-prolonging therapies and aims to provide additional emotional and spiritual support to the patient and family, the finding that nearly one-quarter of patients refused PC may demonstrate a pervasive misconception and need for patient education.
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Affiliation(s)
- Kyle M Rei
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | - Vedhika Reddy
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
- Neurosurgery, California University of Science and Medicine, Colton, USA
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Tielemans LML, van Heugten KD, Hamaker ME, van Walree IC. Preferred and actual involvement of caregivers in oncologic treatment decision-making: A systematic review. J Geriatr Oncol 2023; 14:101525. [PMID: 37198027 DOI: 10.1016/j.jgo.2023.101525] [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: 12/21/2022] [Revised: 04/04/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Treatment decision-making in cancer is complex and many patients bring their caregiver to appointments to help them make those decisions. Multiple studies show the importance of involving caregivers in the treatment decision-making process. We aimed to explore the preferred and actual involvement of caregivers in the decision-making process of patients with cancer and to see if there are age or cultural background related differences in caregiver involvement. MATERIALS AND METHODS A systematic review of Pubmed and Embase was performed on January 2, 2022. Studies containing numerical data regarding caregiver involvement were included, as were studies describing the agreement between patients and caregivers regarding treatment decisions. Studies assessing solely patients aged younger than 18 years old or terminally ill patients, and studies without extractable data were excluded. Risk of bias was assessed by two independent reviewers using an adapted version of the Newcastle-Ottawa scale. Results were analysed in two separate age groups, one <62 years and one ≥62 years. RESULTS Twenty-two studies with a total of 11,986 patients and 6,260 caregivers were included in this review. A median of 75% of patients preferred caregivers to be involved in decision-making and a median of 85% of caregivers preferred to be involved. With regards to age groups, the preferred involvement of caregivers was more frequent in the younger study populations. With regards to geographical differences, studies performed in Western countries showed a lower preference for caregiver's involvement compared to studies from Asian countries. A median of 72% of the patients reported the caregiver was actually involved in the treatment decision-making and a median of 78% of the caregivers reported they were actually involved. The most important role of caregivers was to listen and provide emotional support. DISCUSSION Patients and caregivers both want caregivers to be involved in the treatment decision-making process and most caregivers are actually involved. An ongoing dialogue between clinicians, patients and caregivers about decision-making is important to meet the individual patient's and caregiver's needs when involved in the decision-making process. Important limitations were a lack of studies in older patients and significant differences in outcome measures among studies.
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Affiliation(s)
- Laura M L Tielemans
- Department of Geriatric Medicine, Elisabeth-Twee Steden Ziekenhuis, Tilburg, the Netherlands.
| | - Kirsten D van Heugten
- Department of Geriatric Medicine, Elisabeth-Twee Steden Ziekenhuis, Tilburg, the Netherlands
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, the Netherlands
| | - Inez C van Walree
- Department of Geriatric Medicine, University Medical Centrum Utrecht, Utrecht, the Netherlands
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Lincoln TE, Buddadhumaruk P, Arnold RM, Scheunemann LP, Ernecoff NC, Chang CCH, Carson SS, Hough CL, Curtis JR, Anderson W, Steingrub J, Peterson MW, Lo B, Matthay MA, White DB. Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician. Chest 2023; 163:1214-1224. [PMID: 36336000 PMCID: PMC10258434 DOI: 10.1016/j.chest.2022.10.028] [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: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting. RESEARCH QUESTION Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician? STUDY DESIGN AND METHODS A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores. RESULTS In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model. INTERPRETATION The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.
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Affiliation(s)
- Taylor E Lincoln
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA.
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Leslie P Scheunemann
- Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Chung-Chou H Chang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Shannon S Carson
- Division of Pulmonary Disease and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Wendy Anderson
- Department of Medicine and Division of Hospital Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Jay Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA and Tufts University School of Medicine, Boston, MA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Chan Medical School, Baystate, MA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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10
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Malhotra C, Balasubramanian I. Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time. J Alzheimers Dis 2023:JAD221161. [PMID: 37125548 DOI: 10.3233/jad-221161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time. OBJECTIVE Assess caregivers' EOL care goal for PWSDs and change in these goals over time. METHODS Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point. RESULTS At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals. CONCLUSION Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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11
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Rigaud JP, Ecarnot F, Quenot JP. Patient Information and Consent for Care in the Intensive Care Unit. Healthcare (Basel) 2023; 11:healthcare11050707. [PMID: 36900711 PMCID: PMC10001104 DOI: 10.3390/healthcare11050707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
In this paper, we review the ethical issues involved in providing information to, and obtaining consent (for treatment and/or research) from patients in the intensive care unit. We first review the ethical obligations of the physician in treating patients, who are by definition, vulnerable, and often unable to assert their autonomy during situations of critical illness. Providing clear and transparent information to the patient about treatment options or research opportunities is an ethical and, in some cases, legal obligation for the physicians, but may be rendered difficult, not to say impossible in the intensive care unit by the patient's health state. In this context, we review the specificities of intensive care with respect to information and consent. We discuss who the right contact person is in the ICU setting, with possible choices including a surrogate decision maker, or a member of the family, in the absence of an officially designated surrogate. We further review the specific considerations relating to the family of critically ill patients, and the amount and type of information that may be given to them without breaching the tenets of medical confidentiality. Finally, we discuss the specific cases of consent to research, and patients who refuse care.
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Affiliation(s)
- Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier, 76202 Dieppe, France
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, 14000 Caen, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France
- EA3920, University of Franche-Comté, 25000 Besançon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, Burgundy University Hospital, 21079 Dijon, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21078 Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, 21078 Dijon, France
- Correspondence:
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12
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Shepherd V. (Re)Conceptualising 'good' proxy decision-making for research: the implications for proxy consent decision quality. BMC Med Ethics 2022; 23:75. [PMID: 35850682 PMCID: PMC9294776 DOI: 10.1186/s12910-022-00809-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/06/2022] [Indexed: 11/18/2022] Open
Abstract
People who are unable to make decisions about participating in research rely on proxies to make a decision based on their wishes and preferences. However, patients rarely discuss their preferences about research and proxies find it challenging to determine what their wishes would be. While the process of informed consent has traditionally been the focus of research to improve consent decisions, the more conceptually complex area of what constitutes 'good' proxy decision-making for research has remained unexplored. Interventions are needed to improve and support proxy decision-making for research but are hampered by a lack of understanding about what constitutes decision quality in this context. A global increase in conditions associated with cognitive impairment such as dementia has led to an urgent need for more research into these conditions. The COVID-19 pandemic and subsequent necessity to conduct research with large numbers of critically ill patients has made this need even more pressing. Much of the empirical research centres on the desire to improve decision accuracy, despite growing evidence that authenticity is more reflective of the aim of proxy decisions and concerns about the methodological flaws in authenticity-focused studies. Such studies also fail to take account of the impact of decision-making on proxies, or the considerable body of research on improving the quality of healthcare decisions. This paper reports a concept synthesis of the literature that was conducted to develop the first conceptualisation of 'good' proxy decisions about research participation. Elements of decision quality were identified across three stages of decision-making: proxy preparedness for decision-making which includes knowledge and understanding, and values clarification and preference elicitation; the role of uncertainty, decisional conflict, satisfaction and regret in the decision-making process; and preference linked outcomes and their effect. This conceptualisation provides an essential first step towards the future development of interventions to enhance the quality of proxy decision-making and ensure proxy decisions represent patients' values and preferences.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 0GB, UK.
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13
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The effect of a family-based participatory care program on anxiety in patients with acute coronary syndrome in coronary care units: A randomised controlled clinical trial. Aust Crit Care 2022:S1036-7314(22)00058-3. [PMID: 35618611 DOI: 10.1016/j.aucc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/31/2022] [Accepted: 04/12/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Admission to the coronary care units (CCUs) and the patient's reduced interaction with family are regarded as important sources of anxiety. Family participation in care programs is pivotal to patient outcomes. OBJECTIVES The present study was conducted to determine the effect of a care program based on family participation on anxiety in patients with acute coronary syndrome. METHODS This randomised controlled trial was conducted on 90 patients in CCUs and their families. The patients were randomly assigned to one of the following three groups: routine care, control, and intervention. Routine care measures were provided to the routine care group, increased participation of the family was ensured in the control group, and a family-based participatory care program was implemented in the intervention group with the interaction of the nurse, patient, and family based on five principles, including presence, determination of needs, communication, participation in decision-making, and cooperation in care. The patients' anxiety was measured in the three groups on day 1 and 3 days after the admission to the CCU using the Spielberger State-Trait Anxiety Inventory. RESULTS The patients' mean state anxiety score before the intervention was 44.4 ± 12.7, 46.6 ± 12.4, and 45.5 ± 12.1 in the routine care, control, and intervention groups, respectively, with no significant differences between them (P = 0.81). After adjusting for anxiety before the intervention and study hospital, the mean (before-after) changes in anxiety score in the three groups showed that anxiety was significantly lower in the intervention group than in the other groups (P < 0.05). CONCLUSION Increased family presence alone has no effect on the patients' anxiety, but the family's participation and interaction with the care team can affect anxiety levels in cardiac patients in CCUs and improve the care processes. TRIAL REGISTRATION Iranian Registry of Clinical Trials, Trial No. IRCT201105146481N1.
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14
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Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial. Crit Care Med 2022; 50:1296-1305. [PMID: 35607975 DOI: 10.1097/ccm.0000000000005583] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients. DESIGN Randomized controlled trial. SETTING Single, urban academic medical center. SUBJECTS Surrogates of nondecisional, critically ill adults with high risk of mortality (n = 252) enrolled from June 2019 to January 2021. INTERVENTIONS Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day. MEASUREMENTS AND MAIN RESULTS Participants completed surveys at three time points during the ICU stay: enrollment (n = 252), 1 week (n = 229), and 2 weeks (n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment (p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2-16.0) versus 16.4, (95% CI, 15.5-17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03-0.82; p = 0.03); 0.15 (95% CI, 0.01-1.87; p = 0.14); and 0.27 (95% CI, 0.06-1.27; p = 0.10), respectively. CONCLUSIONS Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.
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15
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Guerin RM. Mechanisms of defense in clinical ethics consultation. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:119-130. [PMID: 34741698 DOI: 10.1007/s11019-021-10057-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 06/13/2023]
Abstract
Clinical ethics consultants respond to a multitude of issues, ranging from the cognitive to the emotional. As such, ethics consultants must be prepared to analyze as well as empathize. And yet, there remains a paucity of research and training on the interpersonal and emotional aspects of clinical ethics consultations-the so-called skills in "advanced ethics facilitation." This article is a contribution to the need for further understanding and practical knowledge in the emotional aspects of ethics consultation. In particular, I draw attention to defense mechanisms: what they are, why they exist, and how we might work with them in the setting of ethics consultation.
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Affiliation(s)
- Robert M Guerin
- Cleveland Medical Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
- Department of Bioethics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
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16
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Ge C, Goss AL, Crawford S, Goostrey K, Buddadhumaruk P, Shields AM, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study. Crit Care Explor 2022; 4:e0640. [PMID: 35224505 PMCID: PMC8863127 DOI: 10.1097/cce.0000000000000640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.
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Affiliation(s)
- Connie Ge
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adeline L Goss
- Department of Internal Medicine, Division of Neurology, Highland Hospital, Oakland, CA
| | - Sybil Crawford
- Department of Graduate School of Nursing, University of Massachusetts Tan Chingfen Graduate School of Nursing, Worcester, MA
| | - Kelsey Goostrey
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Anne-Marie Shields
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Catherine L Hough
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Oregon Health Sciences University, Portland, OR
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Shannon S Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jay Steingrub
- Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
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17
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Keuper K, England AE, Shah RC, Quinn TV, Gerhart J, Greenberg JA. Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome. J Palliat Med 2021; 25:907-914. [PMID: 34964669 DOI: 10.1089/jpm.2021.0348] [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: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R2 = 0.03, p = 0.13) and (R2 = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R2 = 0.34, p < 0.01) and (R2 = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.
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Affiliation(s)
- Kevin Keuper
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ashley Eaton England
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Raj C Shah
- Department of Family Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas V Quinn
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - James Gerhart
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jared A Greenberg
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois, USA
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A psychometric evaluation of the Family Decision-Making Self-Efficacy Scale among surrogate decision-makers of the critically ill. Palliat Support Care 2021; 18:537-543. [PMID: 31699176 DOI: 10.1017/s1478951519000907] [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: 01/02/2023]
Abstract
OBJECTIVES The purpose of this study was to report the psychometric properties, in terms of validity and reliability, of the Unconscious Version of the Family Decision-Making Self-Efficacy Scale (FDMSE). METHODS A convenience sample of 215 surrogate decision-makers for critically ill patients undergoing mechanical ventilation was recruited from four intensive care units at a tertiary hospital. Cross-sectional data were collected from participants between days 3 and 7 of a decisionally impaired patient's exposure to acute mechanical ventilation. Participants completed a self-report demographic form and subjective measures of family decision-making self-efficacy, preparation for decision-making, and decisional fatigue. Exploratory factor analyses, correlation coefficients, and internal consistency reliability estimates were computed to evaluate the FDMSE's validity and reliability in surrogate decision-makers of critically ill patients. RESULTS The exploratory factor analyses revealed a two-factor, 11-item version of the FDMSE was the most parsimonious in this sample. Furthermore, modified 11-item FDMSE demonstrated discriminant validity with the measures of fatigue and preparation for decision-making and demonstrated acceptable internal consistency reliability estimates. SIGNIFICANCE OF RESULTS This is the first known study to provide evidence for a two-factor structure for a modified, 11-item FDMSE. These dimensions represent treatment and palliation-related domains of family decision-making self-efficacy. The modified FDMSE is a valid and reliable instrument that can be used to measure family decision-making self-efficacy among surrogate decision-makers of the critically ill.
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Defining Familial Interactions and Networks: An Exploratory Qualitative Study on Family Networks and Surrogate Decision-Making. Crit Care Explor 2021; 3:e0504. [PMID: 34345829 PMCID: PMC8323795 DOI: 10.1097/cce.0000000000000504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To characterize patient preferences for medical surrogate decision-makers in the ICU to capture the complexity of decision-making preferences and highlight potential conflicts between patients’ preferences and clinicians’ surrogate decision-maker identification in usual clinical practice. DESIGN: Prospective qualitative cross-sectional study. SETTING: Two ICUs in a quaternary referral center in the eastern United States. PATIENTS: Convenience sample of patients admitted to the ICU and their family members. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Twenty-six patient-family-clinician units were interviewed. Men were three times more likely than women to have a legally appointed decision-maker that matched their preferred decision-maker as expressed in the interview. Patients who were married or in a long-term relationship were the most consistent group of respondents, with 94% of them selecting their spouse or partner as the preferred decision-maker. The most common reasons for selecting a surrogate decision-maker were intangible themes such as feeling “known” by that person rather than having prior discussions about specific wishes or advance directives. CONCLUSIONS: Asking about a patient’s familial network and qualities they value in a surrogate decision-maker may aid ICU teams in honoring patients’ wishes for surrogate decision-making. This may be an important supplement to accepted legal hierarchies for proxy decision-makers and advance directive documents. Further studies with larger sample sizes could be used to shed light on the nuances of familial and relationship networks of a more diverse population of respondents.
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Krutsinger DC, Courtright KR, Estabrooks PA. Historic Abuses, Present Disparities, and Systemic Racism: Threats to Surrogate Decision-making for Critical Care Research Enrollment. Ann Am Thorac Soc 2021; 18:1118-1120. [PMID: 34242151 PMCID: PMC8328362 DOI: 10.1513/annalsats.202103-386ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center
- Department of Biostatistics, Epidemiology, and Informatics, and
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Estabrooks
- Department of Health Promotion; and
- Center for Reducing Health Disparities, University of Nebraska Medical Center, Omaha, Nebraska; and
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Abstract
OBJECTIVES To provide a concise review of data and literature pertaining to the etiologies of conflict in the ICU, as well as current approaches to conflict management. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing conflict in the ICU as well as prevention and management strategies. STUDY SELECTION Descriptive and interventional studies addressing conflict, bioethics, clinical ethics consultation, palliative care medicine, conflict management, and conflict mediation in critical care. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for critical care practice and training. DATA SYNTHESIS Conflict frequently erupts in the ICU between patients and families and care teams, as well as within and between care teams. Conflict engenders a host of untoward consequences for patients, families, clinicians, and facilities rendering abrogating conflict a key priority for all. Conflict etiologies are diverse but understood in terms of a framework of triggers. Identifying and de-escalating conflict before it become intractable is a preferred approach. Approaches to conflict management include utilizing clinical ethics consultation, and palliative care medicine clinicians. Conflict Management is a new technique that all ICU clinicians may use to identify and manage conflict. Entrenched conflict appears to benefit from Bioethics Mediation, an approach that uses a neutral, unaligned mediator to guide parties to a mutually acceptable resolution. CONCLUSIONS Conflict commonly occurs in the ICU around difficult and complex decision-making. Patients, families, clinicians, and institutions suffer undesirable consequences resulting from conflict, establishing conflict prevention and resolution as key priorities. A variety of approaches may successfully identify, manage, and prevent conflict including techniques that are utilizable by all team members in support of clinical excellence.
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22
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Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study. Crit Care Med 2021; 48:645-653. [PMID: 32310619 PMCID: PMC7161724 DOI: 10.1097/ccm.0000000000004221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is available in the text. To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.
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Rath KA, Tucker KL, Lewis A. Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting. Am J Hosp Palliat Care 2021; 39:79-85. [PMID: 34002621 DOI: 10.1177/10499091211017872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. METHODS Case report and discussion of the associated ethical issues. RESULTS We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. CONCLUSION It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.
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Affiliation(s)
- Kelly A Rath
- Department of Neurocritical Care, Gardner Neuroscience Institute, University of Cincinnati, OH, USA
| | - Kristi L Tucker
- Section on Neurocritical Care, Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Sellars M, Tran J, Nolte L, White B, Sinclair C, Fetherstonhaugh D, Detering K. Public knowledge, preferences and experiences about medical substitute decision-making: a national cross-sectional survey. BMJ Support Palliat Care 2021:bmjspcare-2020-002619. [PMID: 33722813 DOI: 10.1136/bmjspcare-2020-002619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/01/2021] [Accepted: 02/12/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the Australian adult public's knowledge and experiences regarding substitute decision-making for medical decisions and their preferences for obtaining information about the substitute decision-maker (SDM) role. METHODS This is a national cross-sectional online survey of the Australian adult public. The survey examined participants' advance care planning (ACP) awareness and experience, SDM experiences and preferences for obtaining more information about SDM, and participant knowledge about SDM. RESULTS Of 1586 people who opened the survey, 1120 (70.6%) were included in the final sample. 13% (n=142) of participants indicated they had acted as an SDM. A median score of two correct responses out of five showed low to moderate knowledge about the SDM role among all participants, with only 33% reporting awareness of SDM laws existing in Australia. While most (59%) participants ranked a health professional as their preferred source of obtaining information about supporting SDMs, few participants who had been an SDM (n=64, 45%) reported obtaining any support in making medical decisions. The median SDM knowledge scores for people who had discussed ACP (3.0 vs 2.0, U=1 45 222, z=6.910, p<0.001), documented their ACP preferences (3.0 vs 2.0, U=71 984, z=4.087, p<0.001) or acted in the SDM role (3.0 vs 2.0, U=56 353, z=-3.694, p<0.001) were significantly higher compared with those who had not. CONCLUSIONS The Australian public may have low to moderate knowledge about the SDM role and access only minimal support when making challenging medical decisions.
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Affiliation(s)
- Marcus Sellars
- Department of Health Services Research & Policy, The Australian National University, Canberra, Australian Capital Territory, Australia
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Julien Tran
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Linda Nolte
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Craig Sinclair
- Australian Research Council Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney, New South Wales, Australia
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia
| | - Karen Detering
- Advance Care Planning Australia, Austin Health, Melbourne, Victoria, Australia
- Faculty of Health, Arts and Innovation, Swinburne University, Melbourne, Victoria, Australia
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Wang X, Lopez RP, Rogers AH, Li Y, Ma Y, Zhang Y. Psychometric Properties of the Chinese Version of the Surrogate Decision-Making Self-Efficacy Scale. Res Gerontol Nurs 2021; 14:17-23. [PMID: 33464354 DOI: 10.3928/19404921-20201109-01] [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: 05/06/2020] [Accepted: 08/14/2020] [Indexed: 11/20/2022]
Abstract
Surrogate decision making for patients in the intensive care unit (ICU) can have negative physical and emotional health consequences for the decision-maker. Improving confidence and self-efficacy may reduce these consequences, but a valid instrument is necessary for reliable measurement. Using a cross-sectional design, the current study aimed to translate the Surrogate Decision-Making Self-Efficacy Scale (SDM-SES) into Chinese and evaluate its psychometric properties for surrogate decision-makers (SDMs) of patients in the ICU. The English version of the SDM-SES was translated into Chinese according to Brislin's translation guidelines and tested in 107 Chinese SDMs of patients in the ICU. Cronbach's alpha coefficient was 0.86, and a confirmatory factor analysis yielded acceptably high goodness-of-fit. Scores of the Chinese version of the SDM-SES were positively correlated with General Self-Efficacy Scale scores and 10-item Connor-Davidson Resilience Scale scores. This study indicates that the Chinese version of the SDM-SES has sufficient psychometric properties for assessing self-efficacy of SDMs for patients in the ICU. [Research in Gerontological Nursing, 14(1), 17-23.].
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26
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Lank RJ, Shafie-Khorassani F, Zhang X, Ortiz C, Kim S, Case E, Creutzfeldt CJ, Morgenstern LB, Zahuranec DB. Advance Care Planning and Transitions to Comfort Measures after Stroke. J Palliat Med 2020; 24:1191-1196. [PMID: 33370167 DOI: 10.1089/jpm.2020.0587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Advance care planning (ACP) is recommended to align treatment with patient goals, although there has been little study of the impact of ACP on in-hospital stroke treatment. Objective: To examine the association between ACP and transitions to comfort measures after stroke. Design: Prospective cohort study. Setting/Subjects: Hospitalized stroke patients 45 years and older and surrogate decision makers from a population-based study in Corpus Christi, TX. Measurements: Surrogates were interviewed to assess presence of patient prestroke ACP, categorized as none, informal conversations only, or formal documentation. Patient records were reviewed for time from admission to transition to comfort measures only (CMO) (defined as in-hospital comfort measures or discharge with hospice services). Cox proportional-hazards models assessed the relationship between ACP and time to transition to CMO. Results: Of 148 included stroke patients, 37% transitioned to CMO (median time five days). For ACP, 44% had only informal conversations, 38% had formal documentation (98% of which also reported informal conversations), and 18% had neither. After adjustment for age, severity, and baseline disability, informal conversations alone (hazard ratio [HR] 3.55; 95% confidence interval [CI]: 1.35-9.33) and formal documentation (HR 2.85; 95% CI: 1.05-7.72) were associated with earlier transition to comfort measures compared to no ACP. There was no difference between formal documentation and informal conversations on time to comfort measures (HR 0.80, 95% CI: 0.40-1.63). Conclusions: There was no additional association of formal ACP documentation over informal conversations on time to transition to comfort measures after stroke. Further study of formal ACP is warranted.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatema Shafie-Khorassani
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Xingyu Zhang
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin Case
- Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
| | | | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA.,Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
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27
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Lipnick D, Green M, Thiede E, Smith TJ, Lehman EB, Johnson R, La IS, Wiegand D, Levi BH, Van Scoy LJ. Surrogate Decision Maker Stress in Advance Care Planning Conversations: A Mixed-Methods Analysis From a Randomized Controlled Trial. J Pain Symptom Manage 2020; 60:1117-1126. [PMID: 32645452 PMCID: PMC8109394 DOI: 10.1016/j.jpainsymman.2020.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Spokespersons serving as surrogate decision makers for their loved ones report high levels of stress. Despite known benefits, advance care planning (ACP) conversations often do not occur. More information is needed to understand spokesperson stress during ACP. OBJECTIVES To explore if and how spokespersons perceive stress related to ACP conversations; compare factors related to stress; and assess whether ACP intervention impacted stress. METHODS Secondary and mixed-methods analysis with data transformation of semistructured interviews occurring during a 2 × 2 factorial (four armed) randomized controlled trial that compared standard online ACP to a comprehensive online ACP decision aid. Tools were completed by patients with advanced illness (n = 285) alone or with their spokesperson (n = 285). About 200 spokesperson interviews were purposively sampled from each of the four arms (50 per arm). RESULTS ACP conversations were reported as stressful by 54.41% (74 of 136) and nonstressful by 45.59% (62 of 136). Five themes impacting spokesperson stress were the nature of the relationship with their loved one; self-described personality and belief systems; knowledge and experience with illness and ACP conversations; attitude toward ACP conversations; and social support in caregiving and decision making. No significant differences in stress were associated with arm assignment. CONCLUSION Identifying what factors impact spokesperson stress in ACP conversations can be used to help design ACP interventions to more appropriately address the needs and concerns of spokespersons.
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Affiliation(s)
- Daniella Lipnick
- Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Michael Green
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elizabeth Thiede
- Penn State College of Nursing, University Park, Pennsylvania, USA
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Erik B Lehman
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rhonda Johnson
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - In Seo La
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Debra Wiegand
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Pediatrics, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Public Health Sciences at Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Spalding R, Edelstein B. Factors predicting collaborative willingness of surrogates making medical decisions on the Physician Order for Scope of Treatment (POST). Aging Ment Health 2020; 24:1543-1552. [PMID: 31496268 DOI: 10.1080/13607863.2019.1660854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: The Physician's Order for Scope of Treatment (POST) indicates patient preferences regarding cardiopulmonary resuscitation (CPR), levels of care, and fluids/nutrition provision decisions. When patients become incapacitated, 'surrogates' often collaborate with physicians on POST decisions. Surrogates may vary in their willingness to collaborate, which can be problematic when physicians expect shared decision-making. No research has yet investigated collaborative decision-making among surrogates on the POST. This study investigated how six psychological variables predicted participants' desires for collaboration when completing an online decision-making task.Methods: Participants served as hypothetical surrogates and made decisions for another person on the three sections of the West Virginia POST. One-hundred-and-seventy-two adults were recruited from Amazon Mechanical Turk.Results: The six variables contributed significantly to the prediction of collaborative willingness, F (6, 163) = 5.29, p < .001, R2= 0.19. Two variables uniquely contributed: confidence and consideration of future consequences. The model most strongly predicted collaborative willingness for the CPR decision.Conclusion: This study provides a novel examination of under-researched areas: surrogate collaborative willingness and the POST. Differing risks associated with the three POST decisions may influence how surrogates value collaboration. Ways to enhance collaborative willingness when making POST decisions are discussed.
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Affiliation(s)
- Rachael Spalding
- Department of Psychology, West Virginia University, Morgantown, WV, USA
| | - Barry Edelstein
- Department of Psychology, West Virginia University, Morgantown, WV, USA
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29
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Markovitz N, Morgenstern LB, Shafie-Khorassani F, Cornett BA, Kim S, Ortiz C, Lank RJ, Case E, Zahuranec DB. Family Perceptions of Quality of End-of-Life Care in Stroke. Palliat Med Rep 2020; 1:129-134. [PMID: 32856025 PMCID: PMC7446249 DOI: 10.1089/pmr.2020.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Most end-of-life decisions after stroke are made by a surrogate decision maker, yet there has been limited study of surrogate assessment of the quality of end-of-life stroke care. Objective: To assess surrogate perceptions of quality of end-of-life care (QEOLC) in stroke and explore factors associated with quality. Design: Cross-sectional analysis of interviewer-administered survey. Settings/subjects: Surrogate decision makers for deceased stroke patients in a population-based study. Measurements: The primary outcome was the validated 10-item family version of the QEOLC scale. The univariate association between prespecified patient and surrogate factors and dichotomized QEOLC score (high: 8-10, low: 0-7) was explored with logistic regression fit using generalized estimating equations. Results: Seventy-nine surrogates for 66 deceased stroke cases were enrolled (median patient age: 76, female patient: 53%, Mexican American patient: 59%, median time from stroke to death: seven days, median surrogate age: 59, and female surrogate: 72%). The overall QEOLC was generally high (median 8.3, quartiles 6.1, 9.6) although several individual items had a high proportion (∼30%-50%) of surrogates who felt that the questions did not apply to the patient's situation. No hypothesized factors were associated with QEOLC score, including demographics, stroke type, location/timing of death, advance directives, health literacy, or understanding of patient wishes. Conclusions: Surrogates reported generally high QEOLC. Although this finding is encouraging, modifications to the QEOLC may be needed in stroke as some surrogates were unable to provide a valid response for certain items.
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Affiliation(s)
| | - Lewis B Morgenstern
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Epidemiology and University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Fatema Shafie-Khorassani
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Bridget A Cornett
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sehee Kim
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Carmen Ortiz
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Rebecca J Lank
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Erin Case
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Epidemiology and University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Darin B Zahuranec
- Stroke Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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30
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Chen EP, Arslanian-Engoren C, Newhouse W, Egleston D, Sahgal S, Yande A, Fagerlin A, Zahuranec DB. Development and usability testing of Understanding Stroke, a tailored life-sustaining treatment decision support tool for stroke surrogate decision makers. BMC Palliat Care 2020; 19:110. [PMID: 32689982 PMCID: PMC7370629 DOI: 10.1186/s12904-020-00617-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool. METHODS We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool. RESULTS Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback. CONCLUSION We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers. TRIAL REGISTRATION ClinicalTrials.gov ( NCT03427645 ).
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Affiliation(s)
- Emily P Chen
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, USA
| | - Cynthia Arslanian-Engoren
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, USA
| | - William Newhouse
- Center for Health Communications Research, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | - Diane Egleston
- Center for Health Communications Research, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA
| | | | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, USA
| | - Darin B Zahuranec
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, USA.
- Department of Neurology, University of Michigan Medical School, Ann Arbor, USA.
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31
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What would people think? Perceived social norms, willingness to serve as a surrogate, and end-of-life treatment decisions. Palliat Support Care 2020; 19:46-54. [PMID: 32665048 DOI: 10.1017/s1478951520000401] [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: 11/06/2022]
Abstract
BACKGROUND Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals' willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. METHOD An online sample (N = 172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined person of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers) and choice of end-of-life treatments. RESULTS Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients' physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. SIGNIFICANCE OF RESULTS The current study's consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making - the initial decision to serve as surrogate, and the surrogate's selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making. For instance, providers can be sensitive to potential cultural differences in surrogate decision-making tendencies or employing decision aids that bolster surrogates' confidence in their decisions.
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Visvanathan A, Mead GE, Dennis M, Whiteley WN, Doubal FN, Lawton J. The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. BMC Med Inform Decis Mak 2020; 20:98. [PMID: 32487145 PMCID: PMC7268726 DOI: 10.1186/s12911-020-01137-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 12/01/2022] Open
Abstract
Background Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient’s treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. Method Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. Results Families’ approach to treatment decision-making lay on a spectrum according to the patient’s state of health pre-stroke (i.e. patient’s prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients’ deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. Conclusion The knowledge that family members’ treatment decision-making approaches lay on a spectrum depending on the patient’s state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient’s prognosis. This may enable doctors to provide information and support that is tailored towards family members’ needs.
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Affiliation(s)
- A Visvanathan
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK.
| | - G E Mead
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - M Dennis
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - W N Whiteley
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - F N Doubal
- Clinical Academic Fellow (Chief Scientist Office), Centre for Clinical Brain Sciences, The University of Edinburgh, 49 Chancellor's Building, Edinburgh, EH16 4SB, UK
| | - J Lawton
- Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
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33
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Su Y, Yuki M, Hirayama K. The experiences and perspectives of family surrogate decision-makers: A systematic review of qualitative studies. PATIENT EDUCATION AND COUNSELING 2020; 103:1070-1081. [PMID: 31866198 DOI: 10.1016/j.pec.2019.12.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/09/2019] [Accepted: 12/14/2019] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Surrogate decision-makers play an increasingly important role in the lives of older adults who have lost their ability to make decisions. Currently, there is a lack of evidence to support family surrogates in making a variety of decisions. Additionally, a greater understanding of family caregivers' experiences and perspectives toward making surrogate decisions is needed. METHODS This study employed a qualitative systematic review and thematic synthesis of the research evidence using the methodologies of the Joanna Briggs Institute (2014) and Thomas and Harden (2008). RESULTS Decisions were classified per three main types: intensive care treatment, end-of-life treatment, and placement. Six themes were identified concerning surrogates' experiences: struggle and reluctance, seeking reassurance, communication with healthcare professionals, family support, older adults' wishes, and negative impact. CONCLUSION Family surrogates often lack adequate preparation and education regarding decision-making. Quality communication between surrogates and healthcare providers helps reduce the anxiety and guilt experienced when making surrogate decisions. Further research is required to elucidate these experiences with more cultural and racial nuances. PRACTICE IMPLICATIONS This review informs healthcare providers' awareness of the challenges faced by surrogates and fosters improved surrogate decision-making experiences.
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Affiliation(s)
- Ya Su
- Graduate School of Health Sciences, Hokkaido University, Japan
| | - Michiko Yuki
- Faculty of Health Sciences, Hokkaido University, Japan.
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34
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Ullrich A, Theochari M, Bergelt C, Marx G, Woellert K, Bokemeyer C, Oechsle K. Ethical challenges in family caregivers of patients with advanced cancer - a qualitative study. BMC Palliat Care 2020; 19:70. [PMID: 32423444 PMCID: PMC7236546 DOI: 10.1186/s12904-020-00573-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 05/07/2020] [Indexed: 11/26/2022] Open
Abstract
Background Caring for patients with advanced or terminal diseases can confront family caregivers (FC) with ethical challenges. The present study aims at tracing paths connected to ethical challenges among FC of advanced cancer patients by exploring morally troubling situations and related burden, as well as strategies to handle the situation and experience of moral distress from the grieving FC’s perspective. Methods Within a qualitative design, interviews with 12 grieving FC were conducted using a semi-structured interview guide. Data were analysed using grounded theory and abductive reasoning. Results Core phenomena identified were two paths connected to ethical challenges among FC. Ethical challenges occurred in the context of difficult decision-making (Path 1) and in the context of lacking decision-making options when no decision was to be made by FC (Path 2). We found each path to be triggered by distinct sets of morally troubling situations that occurred during the patient’s disease trajectory. In the course of difficult decision-making (Path 1), detrimental external factors could add emotional stress, thus making the decision-making process burdensome. FC used various proactive strategies to overcome those detrimental factors and/or to make the decision. Decisions in conflict with FCs' own moral expectations and values led to moral distress, generating painful emotions. When no decision was to be made by FC (Path 2), FC felt powerless and overrun, which was associated with major emotionality in terms of anxiety and confusion. Either detrimental factors aggravated these feelings to paralyzing shock, or internal resources enabled FC to accept the situation. While acceptance prevented moral distress, paralyzing shock often caused a sense of not meeting their their own moral expectations and values, resulting in moral distress. In both paths, factors were identified that helped FC finding closure and prevented moral residue. Nevertheless, some FC experienced residual moral distress months after the morally troubling situation had occurred. Conclusion Findings provide first information towards understanding paths leading to ethical challenges in FC and can help clinicians to minimize associated emotional burden and moral distress.
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Affiliation(s)
- Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Marianna Theochari
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriella Marx
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany.,Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Woellert
- Department of History and Ethics of Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Quenot JP, Meunier-Beillard N, Ksiazek E, Abdulmalak C, Berrichi S, Devilliers H, Ecarnot F, Large A, Roudaut JB, Andreu P, Dargent A, Rigaud JP. Criteria deemed important by the relatives for designating a reference person for patients hospitalized in ICU. J Crit Care 2020; 57:191-196. [PMID: 32179249 DOI: 10.1016/j.jcrc.2020.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/09/2020] [Accepted: 02/25/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE We investigated the criteria that patients' relatives deem important for choosing, among themselves, the person best qualified to interact with the caregiving staff. METHODS Exploratory, observational, prospective, multicentre study between 1st March and 31st October 2018 in 2 intensive care units (ICUs). A 12-item questionnaire was completed anonymously by family members of patients hospitalized in the ICU 3 and 5 days after the patient's admission. Relatives were eligible if they understood French and if no surrogate had been appointed by the patient prior to ICU admission. More than one relative per patient could participate. RESULTS In total, 87 relatives of 73 patients completed the questionnaire, average age of relatives was 58 ± 15 years, 46% were the spouse, 30% were children/grandchildren. Items classed as being the most important attributes for a reference person were: good knowledge of the patient's wishes and values; an emotional attachment to the patient; being a family member; and having an adequate understanding of the clinical status and clinical history. CONCLUSION This study identifies the attributes considered by relatives to be most important for designating, among themselves, a reference person for a patient hospitalized in the ICU.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, University Hospital François Mitterrand, Dijon, France; Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France; INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France.
| | - Nicolas Meunier-Beillard
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France; DRCI, USMR, CHU Dijon, Bourgogne, France.
| | - Eléa Ksiazek
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France.
| | - Caroline Abdulmalak
- Department of Intensive Care, Centre Hospitalier William Morey, Châlon sur Saône, France.
| | - Samia Berrichi
- Department of Intensive Care, Centre Hospitalier de Dieppe, France
| | - Hervé Devilliers
- Department of Internal Medicine, François Mitterrand University Hospital, Dijon, France.
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, France.
| | - Audrey Large
- Department of Intensive Care, University Hospital François Mitterrand, Dijon, France.
| | - Jean-Baptiste Roudaut
- Department of Intensive Care, University Hospital François Mitterrand, Dijon, France.
| | - Pascal Andreu
- Department of Intensive Care, University Hospital François Mitterrand, Dijon, France.
| | - Auguste Dargent
- Department of Intensive Care, University Hospital François Mitterrand, Dijon, France; Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France.
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier de Dieppe, France; Espace de Réflexion Ethique de Normandie, University Hospital Caen, France.
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Pavlish CL, Henriksen J, Brown-Saltzman K, Robinson EM, Warda US, Farra C, Chen B, Jakel P. A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit. Am J Crit Care 2020; 29:49-61. [PMID: 31968085 DOI: 10.4037/ajcc2020915] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. OBJECTIVE To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. METHODS In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. RESULTS The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. CONCLUSIONS When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.
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Affiliation(s)
| | - Joan Henriksen
- Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis
| | | | - Ellen M. Robinson
- Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Belinda Chen
- Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California
| | - Patricia Jakel
- Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California
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Pattison N, Arulkumaran N, O'Gara G, Connolly B, Humphreys S, Walsh T, Hopkins P, Dark P. Synthesis of qualitative research studies regarding the factors surrounding UK critical care trial infrastructure. BMJ Open 2019; 9:e030815. [PMID: 31871255 PMCID: PMC6937020 DOI: 10.1136/bmjopen-2019-030815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/17/2019] [Accepted: 11/29/2019] [Indexed: 11/20/2022] Open
Abstract
Conducting clinical trials in critical care is integral to improving patient care. Unique practical and ethical considerations exist in this patient population that make patient recruitment challenging, including narrow recruitment timeframes and obtaining patient consent often in time-critical situations. Units currently vary significantly in their ability to recruit according to infrastructure and level of research activity. AIM To identify variability in the research infrastructure of UK intensive care units and their ability to conduct research and recruit patients into clinical trials. DESIGN We evaluated factors related to intensive care patient enrolment into clinical trials in the UK. This consisted of a qualitative synthesis carried out with two datasets of in-depth interviews (distinct participants across the two datasets) conducted with 27 intensive care consultants (n=9), research nurses (n=17) and trial coordinators (n=1) from 27 units across the UK. Primary and secondary analyses of two datasets (one dataset had been analysed previously) were undertaken in the thematic analysis. FINDINGS The synthesis yielded an overarching core theme of normalising research, characterised by motivations for promoting research and fostering research-active cultures within resource constraints, with six themes under this to explain the factors influencing critical care research capacity: organisational, human, study, practical resources, clinician and patient/family factors. There was a strong sense of integrating research in routine clinical practice, and recommendations are outlined. CONCLUSIONS The central and transferable tenet of normalising research advocates the importance of developing a culture where research is inclusive alongside clinical practice in routine patient care and is a requisite for all healthcare individuals from organisational to direct patient contact level.
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Affiliation(s)
- Natalie Pattison
- School of Health and Social Work, University of Hertfordshire and East & North Hertfordshire NHS Trust, Hertfordshire, UK
- East and North Herts NHS Foundation Trust, Hertfordshire, United Kingdom
| | | | | | | | - Sally Humphreys
- Critical Care, West Suffolk Hospitals NHS Trust, Bury Saint Edmunds, UK
| | - Tim Walsh
- Critical Care, University of Edinburgh Royal Infirmary Edinburgh, Edinburgh, UK
| | | | - Paul Dark
- Intensive Care Unit, University of Manchester, Salford, Greater Manchester, UK
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Walter JK, Hill DL, DiDomenico C, Parikh S, Feudtner C. A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review. BMC Palliat Care 2019; 18:116. [PMID: 31864331 PMCID: PMC6925857 DOI: 10.1186/s12904-019-0504-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents. DISCUSSION Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility. CONCLUSIONS Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.
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Affiliation(s)
- Jennifer K. Walter
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Douglas L. Hill
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Concetta DiDomenico
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Shefali Parikh
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
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How Surrogate Decision-Makers for Patients With Chronic Critical Illness Perceive and Carry Out Their Role. Crit Care Med 2019; 46:699-704. [PMID: 29462004 DOI: 10.1097/ccm.0000000000003035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Family members commonly make medical decision for patients with chronic critical illness. This study examines how family members approach this decision-making role in real time. DESIGN Qualitative analysis of interviews with family members in the intervention arm of a randomized controlled communication trial. SETTINGS Medical ICUs at four U.S. hospitals. PARTICIPANTS Family members of patients with chronic critical illness (adults mechanically ventilated for ≥ 7 d and expected to remain ventilated and survive for ≥ 72 hr) who participated in the active arm of a communication intervention study. INTERVENTIONS Family members participated in at least two content-guided, informational, and emotional support meetings led by a palliative care physician and nurse practitioner. MEASUREMENTS AND MAIN RESULTS Grounded theory was used for qualitative analysis of 66 audio recordings of meetings with 51 family members. Family members perceived their role in four main ways: voice of the patient, advocate for the patient, advocate for others, and advocate for oneself. Their decision-making was characterized by balancing goals, sharing their role, keeping perspective, remembering previous experiences, finding sources of strength, and coping with various burdens. CONCLUSIONS Family members take a multifaceted approach as they participate in decision-making. Understanding how surrogates perceive and act in their roles may facilitate shared decision-making among clinicians and families during critical care.
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Bibas L, Peretz-Larochelle M, Adhikari NK, Goldfarb MJ, Luk A, Englesakis M, Detsky ME, Lawler PR. Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e197229. [PMID: 31322688 PMCID: PMC6646989 DOI: 10.1001/jamanetworkopen.2019.7229] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity. OBJECTIVE To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use. DATA SOURCES A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018. STUDY SELECTION Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively. MAIN OUTCOMES AND MEASURES Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use). RESULTS Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04). CONCLUSIONS AND RELEVANCE Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.
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Affiliation(s)
- Lior Bibas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Maude Peretz-Larochelle
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Neill K. Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael J. Goldfarb
- Division of Cardiology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Adriana Luk
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Michael E. Detsky
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Patrick R. Lawler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada
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Rückholdt M, Tofler GH, Randall S, Buckley T. Coping by family members of critically ill hospitalised patients: An integrative review. Int J Nurs Stud 2019; 97:40-54. [PMID: 31132688 DOI: 10.1016/j.ijnurstu.2019.04.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/28/2019] [Accepted: 04/28/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To provide a comprehensive integrative review of research literature on 1) the coping strategies that are reported by adult family members following admission of their adult loved ones to the intensive care unit (ICU), 2) identify which coping strategies are associated with psychological response during this stressful experience, and 3) the factors that are associated with coping strategies. DATA SOURCES Electronic databases: MEDLINE, PubMed, CINAHL, PsycINFO, and EMBASE; reference lists of journal publications. REVIEW METHODS A total of 643 citations or abstracts were initially screened for content relevance, 15 were included in the integrative review, including 7 quantitative, 3 qualitative and 5 mixed methods studies. Included studies were all conducted in the hospital intensive care unit. RESULTS Coping approaches such as self-distraction appear to be associated with lower psychological distress, and avoidant coping and denial associated with increased psychological distress including traumatic stress symptoms. Factors including social support, gender, age, relationship with the patient, decision maker role, and prior ICU experience can influence coping by family members. Uncertainty of the patient's prognosis and recovery heightens the intensity of the emotional response experienced by family members. Such family members appear at increased risk for experiencing depressive symptoms. CONCLUSIONS From the studies reviewed, it is unclear if coping approaches employed by family members mediate psychological responses such as anxiety and depressive symptoms, or whether coping is a response to psychological stress experienced following hospitalisation of their relative. Future research should focus on the relationship between coping and psychological, physiological and health related behaviours in family members following ICU admission that might contribute towards transient increased health risk during this time. Additionally, future research should explore potential interventions to modify coping and promote family well-being following hospitalisation.
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Affiliation(s)
- Monica Rückholdt
- University of Sydney, Australia; Hornsby Ku-Ring-Gai Hospital, Sydney, Australia.
| | - Geoffrey H Tofler
- University of Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
| | - Sue Randall
- Royal North Shore Hospital, Sydney, Australia
| | - Thomas Buckley
- University of Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
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Gray TF, Nolan MT, Clayman ML, Wenzel JA. The decision partner in healthcare decision-making: A concept analysis. Int J Nurs Stud 2019; 92:79-89. [PMID: 30743199 DOI: 10.1016/j.ijnurstu.2019.01.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The decision partner concept emerged to describe someone who contributes to healthcare decision-making with a patient. There is a need for greater precision and consensus surrounding its conceptual definition and use in broader populations. OBJECTIVE To define and describe the decision partner concept within the context of healthcare decision-making. DESIGN A concept analysis. DATA SOURCES We searched the following databases for articles published between 1990-2017: PsychINFO, PubMed, Embase, and CINAHL. We included qualitative, quantitative, or mixed methods studies that used the term decision partner in the context of healthcare decision-making. METHODS We applied the Walker and Avant method to identify the antecedents, attributes, related concepts, consequences, and empirical referents of the concept, with major themes identified. RESULTS From the 112 articles included in this concept analysis, 6 defining attributes of decision partner were identified: (1) has a relationship with the patient, (2) demonstrates a willingness to participate in decision-making, (3) articulates a clear understanding of both the patient's health condition and the decisions that must be made, (4) demonstrates decision-making self-efficacy; (5) exemplifies an emotional capacity to participate in decision-making, and (6) willing to fulfill several supportive roles including patient advocate and the "hub of information". CONCLUSIONS A unifying definition and discussion of the decision partner concept has been developed. Our findings: (1) offer insights into refining the concept across various diseases and healthcare encounters, (2) contribute to developing theoretical models and empirical research to refine antecedents, attributes, consequences, (3) serve as a foundation to develop instruments to measure the concept and (4) highlight the need to design interventions that include and support decision partners in healthcare decision-making.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States.
| | - Marie T Nolan
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States; Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States
| | - Marla L Clayman
- American Institutes for Research, Chicago, IL, United States
| | - Jennifer A Wenzel
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Critical Care Nurses' Qualitative Reports of Experiences With Family Behaviors as Obstacles in End-of-Life Care. Dimens Crit Care Nurs 2019; 37:251-258. [PMID: 30063520 DOI: 10.1097/dcc.0000000000000310] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Critical care nurses (CCNs) frequently provide end-of-life (EOL) care for critically ill patients. Critical care nurses may face many obstacles while trying to provide quality EOL care. Some research focusing on obstacles CCNs face while trying to provide quality EOL care has been published; however, research focusing on family behavior obstacles is limited. Research focusing on family behavior as an EOL care obstacle may provide additional insight and improvement in care. OBJECTIVES We wanted to gather firsthand experiences of CCNs regarding working with families of dying patients. We then wanted to determine the predominant obstacle themes noted when CCNs share these rich experiences in EOL care. METHODS A random geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from a qualitative question on the questionnaire were analyzed. RESULTS Sixty-seven EOL obstacle experiences surrounding issues with families' behavior were analyzed for this study. Experiences were categorized into 8 themes. Top 3 common obstacle experiences included families in denial, families going against patient wishes and advanced directives, and families directing care that negatively impacted patients. CONCLUSIONS In overcoming EOL obstacles, it may be beneficial to have proactive family meetings to align treatment goals and to involve palliative care earlier in the ICU stay.
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Wen FH, Chou WC, Chen JS, Chang WC, Hsieh CH, Tang ST. Evolution and Predictors of Patient–Caregiver Concordance on States of Life-Sustaining Treatment Preferences over Terminally Ill Cancer Patients' Last Six Months of Life. J Palliat Med 2019; 22:25-33. [DOI: 10.1089/jpm.2018.0307] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
- School of Nursing, Chang Gung University, Taoyuan City, Taiwan
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan
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Gul S, Turkman YE, Bakitas MA, Dionne-Odom JN. Surrogates' Perceptions of Service Quality While Making Decisions for ICU Patients. West J Nurs Res 2018; 41:1370-1384. [PMID: 30574823 DOI: 10.1177/0193945918820098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A qualitative secondary analysis was undertaken to identify aspects of health care service quality in an intensive care unit from the perspective of surrogate decision makers (N = 19) who were making decisions for relatives at end of life. Directed content analysis was guided by the Donabedian model of health care quality. Nineteen participants averaged 59 years old and were over half female (53%) and patients' spouses (53%) and adult children (32%). Salient aspects of quality service included surrogate perceptions that clinicians conveyed honesty about the patient's condition and in an easily understandable way; staff were sensitive and responsive to emotions and practical needs; clinicians demonstrated a clear, confident understanding of the patient's condition; and support by clinicians was given for surrogates' choices. Surrogates also commented on the hospital and intensive care unit environment, including cleanliness, comfort, privacy, and noise level. Further research is needed to explore how decision-support strategies might include service quality concepts.
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Affiliation(s)
- Senay Gul
- Hacettepe University, Ankara, Turkey
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Benson JJ, Schwarz B, Tofle RB, Parker Oliver D. The Motivations and Consequences of Dying at Home: Family Caregiver Perspectives. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/02763893.2018.1505460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jacquelyn J. Benson
- Human Development and Family Science, University of Missouri, Columbia, Missouri, USA
| | - Benyamin Schwarz
- Department of Architectural Studies, University of Missouri, Columbia, Missouri, USA
| | - Ruth Brent Tofle
- Department of Architectural Studies, University of Missouri, Columbia, Missouri, USA
| | - Debra Parker Oliver
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
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Dionne-Odom JN, Ejem D, Azuero A, Taylor RA, Rocque GB, Turkman Y, Thompson MA, Knight SJ, Martin MY, Bakitas MA. Factors Associated with Family Caregivers' Confidence in Future Surrogate Decision Making for Persons with Cancer. J Palliat Med 2018; 21:1705-1712. [PMID: 30129873 DOI: 10.1089/jpm.2018.0148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Improving family caregiver preparation for surrogate decision making is a critical priority. Objective: Determine a parsimonious set of intrapersonal factors associated with family caregivers' confidence in making future medical decisions for their relatives with cancer. Methods: Cross-sectional mail survey. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers from communities of eight U.S. cancer centers. Participants completed validated measures of their social and mental health, self-care behaviors, coping styles, and surrogate decision-making confidence. Using linear modeling, the Bayesian information criterion was used to identify factors associated with decision-making confidence. A bootstrap approach was used to conduct penalized inference on the selected model coefficients. Model fit validation was assessed with a random forest ensemble. Results: Caregivers (n = 294) were on average 65.5 years old, mostly female (72.8%), and care recipients' spouse/partner (60.2%). The parsimonious set of factors associated with low caregiver decision-making confidence included less engagement in spiritual growth self-care, more use of avoidant coping, low emotional social support, and younger care recipient age (in-sample R2 = 0.22). These factors were also identified by a random forest approach. After overfitting adjustment (shrunken R2 = 0.09), the strongest associations with low surrogate decision-making confidence were low spiritual growth self-care (adjusted standardized B = 0.17, p = 0.005) and high use of avoidant coping (adjusted standardized B = -0.12, p = 0.049). Discussion: Identifying strategies to enhance spiritual growth and reduce avoidant coping may be promising targets for interventions to improve family caregivers' confidence in future surrogate decision making.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard A Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yasemin Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Moneka A Thompson
- Department of Pastoral Care, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sara J Knight
- Department of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Y Martin
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
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Kappes A, Nussberger AM, Faber NS, Kahane G, Savulescu J, Crockett MJ. Uncertainty about the impact of social decisions increases prosocial behaviour. Nat Hum Behav 2018; 2:573-580. [PMID: 31209312 DOI: 10.1038/s41562-018-0372-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/01/2018] [Indexed: 11/09/2022]
Abstract
Uncertainty about how our choices will affect others infuses social life. Past research suggests uncertainty has a negative effect on prosocial behaviour1-12 by enabling people to adopt self-serving narratives about their actions1,13. We show that uncertainty does not always promote selfishness. We introduce a distinction between two types of uncertainty that have opposite effects on prosocial behaviour. Previous work focused on outcome uncertainty (uncertainty about whether or not a decision will lead to a particular outcome). However, as soon as people's decisions might have negative consequences for others, there is also impact uncertainty (uncertainty about how others' well-being will be impacted by the negative outcome). Consistent with past research1-12, we found decreased prosocial behaviour under outcome uncertainty. In contrast, prosocial behaviour was increased under impact uncertainty in incentivized economic decisions and hypothetical decisions about infectious disease threats. Perceptions of social norms paralleled the behavioural effects. The effect of impact uncertainty on prosocial behaviour did not depend on the individuation of others or the mere mention of harm, and was stronger when impact uncertainty was made more salient. Our findings offer insights into communicating uncertainty, especially in contexts where prosocial behaviour is paramount, such as responding to infectious disease threats.
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Affiliation(s)
- Andreas Kappes
- Department of Psychology, City, University of London, London, UK.
| | | | - Nadira S Faber
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Guy Kahane
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
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Implementation of a Nurse-Led Family Meeting in a Neuroscience Intensive Care Unit. Dimens Crit Care Nurs 2018; 35:268-76. [PMID: 27487752 DOI: 10.1097/dcc.0000000000000199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE/OBJECTIVES The aims of this study were to develop, implement, and evaluate the impact of early intensive care unit (ICU) nurse-led family meetings on nurse-family communication, family decision making, and satisfaction of family members. BACKGROUND Intensive care unit nurses are in an ideal position to meet family needs, and family members may cope better with the crisis of an ICU admission if consistent honest information is provided by nurses; however, there are no early ICU family meetings led by bedside nurses. METHODS This quality improvement project was implemented in a 10-bed neuroscience ICU over a 3-month period. A convenience sample of 23 nurses participated in the project. Following development of a communication protocol to facilitate nurse-led meetings, the nurses received education and then implemented the protocol. Thirty-one family members participated in the project. Family members were surveyed before and after the meetings. RESULTS Mean meeting time was 26 (SD, 14) minutes. Following implementation of the meetings, findings demonstrated that families felt that communication improved (P = .02 and P = .008), they had appropriate information for decision making allowing them to feel in control (P = .002), and there was an increase in family satisfaction (P = .001). CONCLUSION Early ICU nurse-led family meetings were feasible, improved communication between ICU nurses and family members, facilitated decision making in ICU families, and increased satisfaction of family members.
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Tsuda S, Nakamura M, Aoki S, Ono H, Takagi M, Ohashi H, Miyachi J, Matsui Y, Ojima T. Impact of Patients' Expressed Wishes on Their Surrogate Decision Makers' Preferred Decision-Making Roles in Japan. J Palliat Med 2018; 21:354-360. [PMID: 29148907 DOI: 10.1089/jpm.2017.0226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shuji Tsuda
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
- Kikugawa Family Medicine Center, Kikugawa, Japan
| | - Mieko Nakamura
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | | | | | | | - Junichiro Miyachi
- The Hokkaido Centre for Family Medicine, Hokkaido, Japan
- Center for Medical Education, Kyoto University, Kyoto, Japan
| | | | - Toshiyuki Ojima
- Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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