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Gross J, Koffman J. Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review. PLoS One 2024; 19:e0299933. [PMID: 38498549 PMCID: PMC10947705 DOI: 10.1371/journal.pone.0299933] [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: 09/12/2023] [Accepted: 02/17/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. AIM To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. DESIGN Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. DATA SOURCES Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. RESULTS Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. CONCLUSIONS Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.
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Affiliation(s)
- Jamie Gross
- Northwick Park and Central Middlesex Hospitals, London North West University Healthcare NHS Trust, Harrow, United Kingdom
- King’s College London, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom
| | - Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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2
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Hendershot KA, Elias MN, Taylor BL, Wahlster S, Creutzfeldt CJ. An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty. Curr Treat Options Neurol 2023; 25:517-529. [PMID: 39055121 PMCID: PMC11271663 DOI: 10.1007/s11940-023-00778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 07/27/2024]
Abstract
Purpose of review We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU). Recent findings Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.
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Affiliation(s)
- Kristopher A. Hendershot
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Maya N. Elias
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Breana L. Taylor
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire J. Creutzfeldt
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, 325 9th Avenue, Box 359775, Seattle, WA 98104‑2499, USA
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3
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Lin J, Cook M, Siegel T, Marterre B, Chapman AC. Time is Short: Tools to Integrate Palliative Care and Communication Skills Education into Your Surgical Residency. JOURNAL OF SURGICAL EDUCATION 2023; 80:1669-1674. [PMID: 37385930 DOI: 10.1016/j.jsurg.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
The need to integrate palliative care (PC) training into surgical education has been increasingly recognized. Our aim is to describe a set of PC educational strategies, with a range of requisite resources, time, and prior expertise, to provide options that surgical educators can tailor for different programs. Each of these strategies has been successfully employed individually or in some combination at our institutions, and components can be generalized to other training programs. Asynchronous and individually paced PC training can be provided using existing resources published by the American College of Surgeons and upcoming SCORE curriculum modules. A multiyear PC curriculum, with didactic components of increasing complexity for more advanced residents, can be applied based on available time in the didactic schedule and local expertise. Simulation-based training in PC skills can be developed to provide objective competency-based training. Finally, a dedicated rotation on a surgical palliative care service can provide the most immersive experience with steps toward clinical entrustment of PC skills for trainees.
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Affiliation(s)
- Joseph Lin
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Buddy Marterre
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Section of Gerontology and Geriatric Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Allyson Cook Chapman
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California.
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4
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Hallet J, Zuckerman J, Guttman MP, Chesney TR, Haas B, Mahar A, Eskander A, Chan WC, Hsu A, Barabash V, Coburn N. Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis. Ann Surg Oncol 2023; 30:694-708. [PMID: 36068425 DOI: 10.1245/s10434-022-12486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/06/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults. PATIENTS AND METHODS We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery. RESULTS Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy. CONCLUSIONS Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.
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Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. .,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada. .,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Jesse Zuckerman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Matthew P Guttman
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Unity Health, Toronto, ON, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Antoine Eskander
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Wing C Chan
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Amy Hsu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Victoria Barabash
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Natalie Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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5
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Rake EA, Box ICH, Dreesens D, Meinders MJ, Kremer JAM, Aarts JWM, Elwyn G. Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:2860-2870. [PMID: 35659466 DOI: 10.1016/j.pec.2022.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Proponents of shared decision-making (SDM) advocate the elicitation of the patient's perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or context. METHODS A search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument). RESULTS The search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed. CONCLUSIONS PPE occurs on a very low level in efforts to achieve SDM according to evaluation studies. PRACTICE IMPLICATIONS PPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.
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Affiliation(s)
- Ester A Rake
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands; Knowledge Institute of Medical Specialists, Utrecht, The Netherlands.
| | - Ivana C H Box
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Dunja Dreesens
- Knowledge Institute of Medical Specialists, Utrecht, The Netherlands.
| | - Marjan J Meinders
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Jan A M Kremer
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Johanna W M Aarts
- Department of Gynaecological oncology, Amsterdam UMC University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Glyn Elwyn
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.
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6
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Hurley VB. Are patients really getting what they want? The routine implementation of decision aids for patients with hip or knee osteoarthritis in the high value healthcare collaborative and alignment between patient treatment choice and receipt. J Eval Clin Pract 2021; 27:1207-1215. [PMID: 33829617 DOI: 10.1111/jep.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Alignment between patients' treatment choices and treatments received is acknowledged as an important outcome of shared decision-making (SDM), yet recent research suggests that patients' choices do not always align with their actual treatment trajectories. This paper explores the alignment of patient-expressed treatment choices (for surgery or medical management) after exposure to decision aids and treatments received among patients with hip or knee osteoarthritis within High Value Healthcare Collaborative (HVHC) systems as the collaborative integrated decision aids intended to support SDM into routine clinical practice. METHOD This retrospective cohort study examines data from adult (≥18 years) patients with hip or knee osteoarthritis who received decision aids as part of orthopaedic consultations within HVHC systems between 2012 and 2015. Multivariable logistic regression explored the association between patient-level characteristics with the odds of treatment choice-receipt alignment. RESULTS The majority of patients with knee osteoarthritis (68.3%) and hip osteoarthritis (71.9%) received treatments aligned with their choices following exposure to decision aids, but analyses reveal important differences in the odds of such alignment across patient characteristics. In adjusted models, African American patients with knee osteoarthritis had 50% lower odds of receiving treatment aligned with their choices compared with Caucasian patients (OR = 0.52, P < .05). Medicare- or Medicaid-insured knee patients had 49% and 59% lower odds (respectively) of receiving choice-aligned treatments relative to privately insured patients. Patients with knee (OR = 0.40, P < .01) or hip (OR = 0.75, P < .05) osteoarthritis at earlier decision-making stages had lower odds of receiving treatments congruent with their choices. CONCLUSION This work elucidates the odds of treatment choice-aligned care for patients within health care systems attempting to routinely integrate decision aids to support SDM into clinical practice and underscores the gaps in achieving this alignment among African American patients, those with public insurance and those at early decision-making stages.
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Affiliation(s)
- Vanessa B Hurley
- Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
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7
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Sokas C, Yeh IM, Coogan K, Bernacki R, Mitchell S, Bader A, Ladin K, Palmer JA, Tulsky JA, Cooper Z. Older Adult Perspectives on Medical Decision Making and Emergency General Surgery: "It had to be Done.". J Pain Symptom Manage 2021; 61:948-954. [PMID: 33038427 PMCID: PMC8024409 DOI: 10.1016/j.jpainsymman.2020.09.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced care planning during an emergency surgery episode. OBJECTIVES We sought to better understand older patients' lived experience making decisions to undergo emergency general surgery (EGS) and perceptions of perioperative advance care planning (ACP). METHODS Adults aged 65 and older who underwent one of seven common EGS procedures with lengths of stay more than five days at three Boston-area hospitals were included. Semistructured phone interviews were conducted three months postdischarge. Transcripts were reviewed and coded independently by surgeons and palliative care physicians to identify themes. RESULTS About 31 patients were interviewed. Patients viewed the decision for surgery as a choice of life over death and valued prolonging life. They felt there was no choice but to proceed with surgery but reported that participation in decision making was limited because of severe symptoms, time constraints, and confused thinking. Despite recently surviving a life-threatening illness, patients had not reconsidered their wishes for the future and preferred to avoid future ACP. CONCLUSION Older patients who survived a life-threatening illness and EGS report receiving goal-concordant care in the moment that relieved symptoms and prolonged life but had not considered future care. Interventions to facilitate postoperative ACP should be targeted to this vulnerable group of older adults.
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Affiliation(s)
- Claire Sokas
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Irene M Yeh
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Susan Mitchell
- Hebrew SeniorLife Arthur and Hinda Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Angela Bader
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Anesthesia, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Jennifer A Palmer
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA; Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA.
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9
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Cohan JN, Orleans B, Brecha FS, Huang LC, Presson A, Fagerlin A, Ozanne EM. Factors Associated With Decision Regret Among Patients With Diverticulitis in the Elective Setting. J Surg Res 2021; 261:159-166. [PMID: 33429225 DOI: 10.1016/j.jss.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND We aimed to identify decision process measures associated with patient decisional regret regarding the decision to pursue elective colectomy or observation for diverticulitis. MATERIALS AND METHODS This was a single-center cross-sectional survey study. We included adult patients treated for diverticulitis between 2014 and 2019 and excluded patients who required urgent or emergent colectomy. The primary outcome was regret regarding the decision to pursue elective surgery or observation for diverticulitis, measured using the Decision Regret Scale. We used multivariable linear regression to examine hypothesized predictors of decision regret, including decisional conflict (Decision Conflict Scale and its subscales), shared decision-making, and decision role concordance. RESULTS Of 923 eligible patients, 133 were included in the analysis. Patients had a median of five episodes of diverticulitis (interquartile range 3-8), occurring a median of 2 y (interquartile range 1-3) before survey administration. Thirty-eight patients (29%) underwent elective surgery for diverticulitis. Decision regret (Decision Regret Scale score ≥25) was present in 42 patients (32%). After controlling for surgery, gender, health status, and years since treatment, decision regret was associated with decisional conflict and inversely associated with values clarity, decision role concordance, shared decision-making, and feeling informed, supported, and effective in decision-making (all P < 0.001). CONCLUSIONS Nearly one-third of survey respondents experienced regret regarding the decision between elective surgery and observation for diverticulitis. Decision regret may be reduced through efforts to improve patient knowledge, values clarity, role concordance, and shared decision-making.
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Affiliation(s)
- Jessica N Cohan
- Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Population Health Sciences, University of Utah, Salt Lake City, Utah.
| | - Brian Orleans
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | | | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Angela Presson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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11
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Marterre B, Shin J, Terzian WTH. Shared Decision-Making in the Context of Uncertain Care Goals and Outcomes: Dissecting a Penetrating Abdominal Trauma Case Complicated by Enterocutaneous Fistulae. Am Surg 2020; 86:1456-1461. [PMID: 33167706 DOI: 10.1177/0003134820960051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgeons care deeply about their patients, their patient's surgical outcomes, and their fund of knowledge as it relates to disease, treatment options, and risk is remarkable. Unfortunately, surgical patients' values, hopes, fears, and unacceptable levels of suffering are rarely elicited and addressed while constructing surgical treatment plans, even when the stakes are high. How can surgeons bring all their experience, education, and expertise to bear in a patient-centered manner amidst uncertainty? Surgeons typically emulate mentors who either employed a solely informative, facilitative, or directive/paternalistic approach to decision-making. These 3 styles fail to simultaneously address: (1) what matters most to patients and (2) the surgeon's expertise. Since communication in each of these 3 approaches is unidirectional, and the decisional power locus is imbalanced, they are unshared, nonpartnering, and-perhaps surprisingly-not patient-centered. Patient-centered, collaborative shared decision-making (SDM) approaches align with palliative care principles and are rarely employed, taught, or modeled. Furthermore, nonpartnering approaches to surgical decision-making are often laden with unintended consequences, such as patient and family suffering and the suffering of surgeons. We present the high-risk case of an abdominal gunshot wound in a morbidly obese man, which was complicated by 3 enterocutaneous fistulae and a loss of abdominal wall integrity, where ongoing empathic, partnering SDM dialogue is enabling a patient-centered and value-concordant care plan. The authors invite you to virtually journey with us as this case unfolds, as the impending surgical decisions are substantial and weighty. Uncertainty and risks appear at every turn-providing additional challenges to overcome.
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Affiliation(s)
- Buddy Marterre
- Department of General Surgery, 12279Wake Forest Baptist Health, Winston-Salem, NC, USA.,Department of Internal Medicine, 12279Wake Forest Baptist Health, Winston-Salem, NC, USA.,School of Medicine, 12279Wake Forest University, Winston-Salem, NC, USA
| | - Jaewook Shin
- School of Medicine, 12279Wake Forest University, Winston-Salem, NC, USA
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12
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Rajasingh CM, Wren SM. Translating Outcomes Data Into Improved Shared Decision-Making in Patients With Left Ventricular Assist Devices. JAMA Netw Open 2020; 3:e2025673. [PMID: 33180126 DOI: 10.1001/jamanetworkopen.2020.25673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Palo Alto Veterans Health Care System, Palo Alto, California
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13
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Diaz Milian R. Barriers to High Quality End of Life Care in the Surgical Intensive Care Unit. Am J Hosp Palliat Care 2020; 38:1064-1070. [PMID: 33118372 DOI: 10.1177/1049909120969970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
End of life discussions frequently take place in surgical intensive care units, as a significant number of patients die while admitted to the hospital, and surgery is common during the last month of life. Multiple barriers exist to the initiation of these conversations, including: miscommunication between clinicians and surrogates, a paternalistic approach to surgical patients, and perhaps, conflicts of interest as an unwanted consequence of surgical quality reporting. Goal discordant care refers to the care that is provided to a patient that is incapacitated and that is not concordant to his/her wishes. This is a largely unrecognized medical error with devastating consequences, including inappropriate prolongation of life and non-beneficial therapy utilization. Importantly, hospice and palliative care needs to be recognized as quality care in order to deter the incentives that might persuade clinicians from offering these services.
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Affiliation(s)
- Ricardo Diaz Milian
- Department of Anesthesiology and Perioperative Medicine, 160343Augusta University, Augusta, GA, USA
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14
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Niburski K, Guadagno E, Mohtashami S, Poenaru D. Shared decision making in surgery: A scoping review of the literature. Health Expect 2020; 23:1241-1249. [PMID: 32700367 PMCID: PMC7696205 DOI: 10.1111/hex.13105] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) has been increasingly implemented to improve health-care outcomes. Despite the mixed efficacy of SDM to provide better patient-guided care, its use in surgery has not been studied. The aim of this study was to systematically review SDM application in surgery. DESIGN The search strategy, developed with a medical librarian, included nine databases from inception until June 2019. After a 2-person title and abstract screen, full-text publications were analysed. Data collected included author, year, surgical discipline, location, study duration, type of decision aid, survey methodology and variable outcomes. Quantitative and qualitative cross-sectional studies, as well as RCTs, were included. RESULTS A total of 6060 studies were retrieved. A total of 148 were included in the final review. The majority of the studies were in plastic surgery, followed by general surgery and orthopaedics. The use of SDM decreased surgical intervention rate (12 of 22), decisional conflict (25 of 29), and decisional regret (5 of 5), and increased decisional satisfaction (17 of 21), knowledge (33 of 35), SDM preference (13 of 16), and physician trust (4 of 6). Time increase per patient encounter was inconclusive. Cross-sectional studies showed that patients prefer shared treatment and surgical treatment varied less. The results of SDM per type of decision aid vary in terms of their outcome. CONCLUSION SDM in surgery decreases decisional conflict, anxiety and surgical intervention rates, while increasing knowledge retained decisional satisfaction, quality and physician trust. Surgical patients also appear to prefer SDM paradigms. SDM appears beneficial in surgery and therefore worth promoting and expanding in use.
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Affiliation(s)
| | - Elena Guadagno
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
| | - Sadaf Mohtashami
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
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Shared Decision Making in Surgery: A Meta-Analysis of Existing Literature. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:667-681. [DOI: 10.1007/s40271-020-00443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Wyman MF, Liebzeit D, Voils CI, Bowers BJ, Chapman EN, Gilmore-Bykovskyi A, Kennelty KA, Kind AJH, Loosen J, Rogus-Pulia N, Dattalo M. "Hopes and wishes": Goals of high-need, high-cost older patients and their caregivers. PATIENT EDUCATION AND COUNSELING 2020; 103:1428-1434. [PMID: 32098745 PMCID: PMC7286795 DOI: 10.1016/j.pec.2020.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/20/2020] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers. METHODS Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers. RESULTS HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security. CONCLUSION Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers. PRACTICE IMPLICATIONS Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population.
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Affiliation(s)
- Mary F Wyman
- Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Daniel Liebzeit
- Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA; School of Nursing, University of Wisconsin, Madison, WI, USA.
| | - Corrine I Voils
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Research Service, W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | | | - Elizabeth N Chapman
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | - Andrea Gilmore-Bykovskyi
- School of Nursing, University of Wisconsin, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | - Korey A Kennelty
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Amy J H Kind
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA; Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI, USA.
| | - Julia Loosen
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Nicole Rogus-Pulia
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | - Melissa Dattalo
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Geriatrics Research, Education and Clinical Center (GRECC), W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
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18
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Controle ineficaz da saúde em pessoas vivendo com AIDS: análise de conteúdo. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ao0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Zens TJ, Kopecky KE, Schwarze ML, Suwanabol PA. Surgery Hurts: Characterizing the Experience of Pain in Surgical Patients as Witnessed by Medical Students. JOURNAL OF SURGICAL EDUCATION 2019; 76:1506-1515. [PMID: 31060970 DOI: 10.1016/j.jsurg.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/16/2019] [Accepted: 04/16/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The patient experience around surgical care is poorly characterized. Medical students have a unique position on the surgical team, which allows them to observe patient experiences that may otherwise be overlooked. The objective of this study was to characterize surgical patients' experience with pain as witnessed by medical students. STUDY DESIGN At the end of an 8-week surgical clerkship, we asked all third-year medical students to write a reflective essay describing one surgical patient in pain. We collected 341 essays over a 4-year period and used qualitative content analysis to explore the students' reports of pain experienced by surgical patients. RESULTS When asked to tell a story about a surgical patient in pain, medical students report vivid descriptions of physical agony, emotional distress, and patient regret. For example, "Throughout the procedure our patient cried out and writhed in agony from the searing pain in his chest," and "The patient was practically shedding tears, complaining of pain, as [we] changed her dressing." The students' accounts reveal wide-ranging physical and emotional suffering among surgical patients, including alterations in self-image and feelings of vulnerability. Pain and suffering were intensified when patients felt they had lost control, in settings of uncertain prognosis and with unexpected outcomes. CONCLUSIONS Students' descriptions of the surgical patient's experience are disturbingly graphic. They expose suffering ranging from generalized discomfort to anguish and excruciating pain. These data suggest that surgical patients have substantial unmet needs with respect to symptom management and emotional support that, if better addressed, could improve the patient experience.
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Affiliation(s)
- Tiffany J Zens
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Kimberly E Kopecky
- Department of Surgery, Stanford University, Stanford, California; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin, Madison, Wisconsin; Department of Medical History and Bioethics, University of Wisconsin, Madison, Wisconsin
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20
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Nakagawa S, Fischkoff K, Berlin A, Arnell TD, Blinderman CD. Communication Skills Training for General Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2019; 76:1223-1230. [PMID: 31005480 DOI: 10.1016/j.jsurg.2019.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/19/2019] [Accepted: 04/02/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Although good communication skills are essential for surgeons, there is no formal communication training during general surgery residency. OBJECTIVES To implement a communication skills training program based on evidence-based teaching methods in general surgery residency. DESIGN We developed a 2-hour communication skills training program for general surgery residents, consisting of a small group skill practice session using role play with simulated patients along with real-time feedback from facilitators and observing peer residents. A board-certified palliative care physician and a board-certified surgeon facilitated each session. Outcome measures were self-assessment of preparedness with the session immediately before and after the session and 2 months after the session, resident satisfaction, and self-report frequency of skill practice. Results were compared between junior residents (postgraduate year 1-3) and senior residents (postgraduate year 4-5). SETTING Columbia University Medical Center in New York City, a tertiary care, urban academic center with a 5-year General Surgery Residency program. PARTICIPANTS Thirty-one out of 39 (79.4%) general surgery residents (20 junior and 11 senior) were trained over a 9-month period. All participants completed the immediate pre- and post-session surveys, and twenty residents (64.5%) completed the 2-month postsession follow-up survey. RESULTS Overall, self-assessment of preparedness for specific communication challenges improved significantly for 7 of 11 tasks. At baseline, senior residents felt significantly more prepared than junior residents in all 11 tasks. Junior residents' self-assessment of preparedness improved significantly in 10 of 11 tasks. Overall satisfaction with the session was very high (mean 4.74 on a 5-point scale). Residents reported high frequency of self-directed skill practice in the 2-month follow-up survey. CONCLUSIONS This 2-hour communication skills practice session for general surgery residents was feasible, and it improved resident self-assessment of preparedness in communication and augmented self-directed skill practice.
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Affiliation(s)
- Shunichi Nakagawa
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York.
| | - Katherine Fischkoff
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Ana Berlin
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York; Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Tracey D Arnell
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, New York, New York
| | - Craig D Blinderman
- Department of Medicine, Adult Palliative Care Services, Columbia University Medical Center, New York, New York
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Childers JW, Arnold RM. Expanding Goals of Care Conversations Across a Health System: The Mapping the Future Program. J Pain Symptom Manage 2018; 56:637-644. [PMID: 30048766 DOI: 10.1016/j.jpainsymman.2018.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Clinician failure to discuss goals of care (GOC) with seriously ill patients remains prevalent. Small-scale educational interventions have demonstrated improvement in physician communication skills, but it is unknown if these results translate into practice changes. OBJECTIVES To implement a large-scale educational intervention that would facilitate increased GOC discussions in at-risk patients, increase clinician confidence in having GOC discussions, and prove to be sustainable. METHODS The Mapping the Future courses were four-to-eight-hour trainings, with brief lectures and demonstrations followed by practice with simulated patient cases. Participants completed precourse and postcourse surveys, including demographic information, self-confidence in a variety of communication tasks, willingness to initiate GOC discussions, barriers to GOC discussions, and self-perceived skill at having GOC conversations. We compared the rate of documentation of GOC discussions with at-risk inpatients in three hospitals for physicians who had taken the course and those who had not. RESULTS Over a two-year period, we trained 512 clinicians in 42 sessions. After the course, participants felt that they had improved in all the skills that we taught and agreed that they would be more likely to initiate GOC conversations. Trained physicians were more likely than their nontrained colleagues to document a GOC discussion with at-risk patients (30.8% vs. 27.2%; P = 0.0001). CONCLUSION A large-scale educational intervention involving simulated patient cases increased GOC documentation across a health system. Other programs might consider collaboration with quality improvement specialists to measure the impact of education and situate it within other system changes to support increased GOC discussions.
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Affiliation(s)
- Julie W Childers
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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