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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [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: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Bayuo J, Kyei Baffour P. Healthcare Staff Perceptions Regarding Barriers and Enablers to End-of-Life Care Provision in Non-Palliative Care Settings in Ghana: A Multicentre Qualitative Study. OMEGA-JOURNAL OF DEATH AND DYING 2024; 89:259-274. [PMID: 35090354 DOI: 10.1177/00302228211072970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The projected rise in health-related suffering warrants the integration of palliative care across all health systems. For traditionally non-palliative care settings, barriers and enablers to palliative care integration remain poorly understood. This study sought to explore these barriers and enablers in the Emergency and Burn Units across two healthcare facilities in the middle belt of Ghana using qualitative description. Thirty-nine healthcare staff comprising 20 burn care staff and 19 ED staff were purposively recruited and interviewed. Interviews were transcribed following which thematic analysis was performed inductively. Two themes and six subthemes emerged from the data. The Ghanaian socio-cultural context often crippled the discussion of death and dying. Overall, there is a perceived tension between emergency/burns and end-of-life care. Opportunities however exist to improve the situation which will require more work regarding curricula improvement, providing avenues for professional development, culturally sensitive communication, and identifying strategies of engaging relatives.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
- Department of Nursing, Presbyterian University College, Ghana
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Fakhry SM, Carrick MM, Hoffman MR, Shen Y, Garland JM, Wyse RJ, Watts DD. Hospice and palliative care utilization in 16 004 232 medicare claims: comparing trauma to surgical and medical inpatients. Trauma Surg Acute Care Open 2024; 9:e001329. [PMID: 38646618 PMCID: PMC11029464 DOI: 10.1136/tsaco-2023-001329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/26/2024] [Indexed: 04/23/2024] Open
Abstract
Background Hospice and palliative care (PC) utilization is increasing in geriatric inpatients, but limited research exists comparing rates among trauma, surgical and medical specialties. The goal of this study was to determine whether there are differences among these three groups in rates of hospice and PC utilization. Methods Patients from Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files for 2016-2020 aged ≥65 years were analyzed. Patients with a National Trauma Data Standard-qualifying ICD-10 injury code with abbreviated injury score ≥2 were classified as 'trauma'; the rest as 'surgical' or 'medical' using CMS MS-DRG definitions. Patients were classified as having PC if they had an ICD-10 diagnosis code for PC (Z51.5) and as hospice discharge (HD) if their hospital disposition was 'hospice' (home or inpatient). Use proportions for specialties were compared by group and by subgroups with increasing risk of poor outcome. Results There were 16M hospitalizations from 1024 hospitals (9.3% trauma, 26.3% surgical and 64.4% medical) with 53.7% women, 84.5% white and 38.7% >80 years. Overall, 6.2% received PC and 4.1% a HD. Both rates were higher in trauma patients (HD: 3.6%, PC: 6.3%) versus surgical patients (HD: 1.5%, PC: 3.0%), but lower than in medical patients (HD: 5.2%, PC: 7.5%). PC rates increased in higher risk patient subgroups and were highest for inpatient HD. Conclusions In this large study of Medicare patients, HD and PC rates varied significantly among specialties. Trauma patients had higher HD and PC utilization rates than surgical, but lower than medical. The presence of comorbidities, frailty and/or severe traumatic brain injury (in addition to advanced age) may be valuable criteria in selection of trauma patients for hospice and PC services. Further studies are needed to inform the most efficient use of hospice and PC resources, with particular focus on both timing and selection of subgroups most likely to benefit from these valuable yet limited resources. Level of evidence Level III, therapeutic/care management.
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Affiliation(s)
- Samir M Fakhry
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare Inc, Nashville, Tennessee, USA
| | | | | | - Yan Shen
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare Inc, Nashville, Tennessee, USA
| | - Jeneva M Garland
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare Inc, Nashville, Tennessee, USA
| | - Ransom J Wyse
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare Inc, Nashville, Tennessee, USA
| | - Dorraine D Watts
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare Inc, Nashville, Tennessee, USA
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Hwang F, Son J, Ensor K, Goulet N, Brown A, Victory J, Tyrie L. Initiating advance care planning at admission: a brief intervention to increase goals of care discussions in geriatric trauma patients in an urban level I trauma center. Trauma Surg Acute Care Open 2023; 8:e001058. [PMID: 38020856 PMCID: PMC10660418 DOI: 10.1136/tsaco-2022-001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The burden of geriatric trauma continues to rise. Older trauma patients experience higher morbidity and mortality and thus benefit from early goals of care (GOC) discussions and advance care planning (ACP). The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) recommends holding a family meeting within 72 hours of admission when treating geriatric trauma patients. At our level I trauma center, we sought to increase early GOC discussions by implementing a new history and physical (H&P) note template for geriatric trauma patients. Methods Patients (aged >65 years) admitted to the trauma surgery service (≥24 hours) were included in the study. The intervention was a change in the H&P note template to include confirmation of code status or previous ACP and identification of a healthcare proxy. Primary outcomes were the rates of recognizing a pre-existing Do-Not-Resuscitate (DNR) status/advanced directives at admission and of documentation of a GOC discussion within 72 hours. Outcomes from a 3-month period (March-May) during the pre-intervention (2021) and post-intervention (2022) periods were compared. Results The pre-intervention and post-intervention groups had 107 and 150 patients, respectively. We observed an increase in recognition of pre-existing DNR code status at time of admission from 50% to 95% (p=0.003) and documentation of a GOC discussion within 72 hours from 17% to 83% (p<0.0001). We also observed a trend showing that new DNR orders were placed more frequently in the post-intervention period (9% vs 17%, p=0.098). The in-hospital mortality was not significantly different. Conclusions The importance of GOC discussions and ACP documentation for geriatric trauma patients is evident, but its completion can be challenging. Our intervention of a new H&P note template increased GOC discussions, and this implementation may be feasible in other trauma centers to comply with the ACS-TQIP Geriatric Trauma Management Guidelines. Level of evidence Level III.
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Affiliation(s)
| | - Joohee Son
- Surgery, NYU Langone Health - Brooklyn, Brooklyn, New York, USA
| | - Kelsey Ensor
- Surgery, NYC Health + Hospitals, Brooklyn, New York, USA
| | - Nicole Goulet
- Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Allison Brown
- Surgery, NYU Langone Health - Brooklyn, Brooklyn, New York, USA
| | - Jesse Victory
- Surgery, NYU Langone Health - Brooklyn, Brooklyn, New York, USA
| | - Leslie Tyrie
- Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
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Hornor M, Khan U, Cripps MW, Cook Chapman A, Knight-Davis J, Puzio TJ, Joseph B. Futility in acute care surgery: first do no harm. Trauma Surg Acute Care Open 2023; 8:e001167. [PMID: 37780455 PMCID: PMC10533797 DOI: 10.1136/tsaco-2023-001167] [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] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/03/2023] Open
Abstract
The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations.
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Affiliation(s)
- Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
| | - Uzer Khan
- Surgery, Texas Christian University, Fort Worth, Texas, USA
| | - Michael W Cripps
- Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Allyson Cook Chapman
- Medicine and Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Knight-Davis
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, The Ohio State University College of Medicine and Public Health, Columbus, Ohio, USA
| | - Thaddeus J Puzio
- General Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bellal Joseph
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, University of Arizona Medical Center—University Campus, Tucson, Arizona, USA
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Bayuo J, Abu-Odah H, Koduah AO. Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review. J Palliat Care 2023; 38:239-253. [PMID: 35603876 DOI: 10.1177/08258597221102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
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Dying in the ICU : Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany. DIE ANAESTHESIOLOGIE 2022; 71:930-940. [PMID: 35925156 DOI: 10.1007/s00101-022-01127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012. METHODS In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012 RESULTS: Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy. CONCLUSION In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.
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Williamson TL, Adil SM, Shalita C, Charalambous LT, Mitchell T, Yang Z, Parente BA, Lee HJ, Ubel PA, Lemmon ME, Galanos AN, Lad SP, Komisarow JM. Palliative Care Consultations in Patients with Severe Traumatic Brain Injury: Who Receives Palliative Care Consultations and What Does that Mean for Utilization? Neurocrit Care 2022; 36:781-790. [PMID: 34988887 PMCID: PMC9117411 DOI: 10.1007/s12028-021-01366-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Palliative care has the potential to improve goal-concordant care in severe traumatic brain injury (sTBI). Our primary objective was to illuminate the demographic profiles of patients with sTBI who receive palliative care encounters (PCEs), with an emphasis on the role of race. Secondary objectives were to analyze PCE usage over time and compare health care resource utilization between patients with or without PCEs. METHODS The National Inpatient Sample database was queried for patients age ≥ 18 who had a diagnosis of sTBI, defined by using International Classification of Diseases, 9th Revision codes. PCEs were defined by using International Classification of Diseases, 9th Revision code V66.7 and trended from 2001 to 2015. To assess factors associated with PCE in patients with sTBI, we performed unweighted generalized estimating equations regression. PCE association with decision making was modeled via its effect on rate of percutaneous endoscopic gastrostomy (PEG) tube placement. To quantify differences in PCE-related decisions by race, race was modeled as an effect modifier. RESULTS From 2001 to 2015, the proportion of palliative care usage in patients with sTBI increased from 1.5 to 36.3%, with 41.6% White, 22.3% Black, and 25% Hispanic patients with sTBI having a palliative care consultation in 2015, respectively. From 2008 to 2015, we identified 17,673 sTBI admissions. White and affluent patients were more likely to have a PCE than Black, Hispanic, and low socioeconomic status patients. Across all races, patients receiving a PCE resulted in a lower rate of PEG tube placement; however, White patients exhibited a larger reduction of PEG tube placement than Black patients. Patients using palliative care had lower total hospital costs (median $16,368 vs. $26,442, respectively). CONCLUSIONS Palliative care usage for sTBI has increased dramatically this century and it reduces resource utilization. This is true across races, however, its usage rate and associated effect on decision making are race-dependent, with White patients receiving more PCE and being more likely to decline the use of a PEG tube if they have had a PCE.
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Affiliation(s)
- Theresa L Williamson
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA.
| | - Syed M Adil
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Chidyaonga Shalita
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Taylor Mitchell
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Beth A Parente
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC, 27710, USA
| | - Monica E Lemmon
- Department of Pediatrics, Duke University Medical Center, Durham, NC, 27710, USA
| | - Anthony N Galanos
- Division of Palliative Care, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Jordan M Komisarow
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
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10
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Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit. J Crit Care Med (Targu Mures) 2022; 8:100-106. [PMID: 35950152 PMCID: PMC9097642 DOI: 10.2478/jccm-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/26/2022] [Indexed: 12/02/2022] Open
Abstract
Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.
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11
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Cross SH, Anderson DM, Cox CE, Agarwal S, Haines KL. Trends in Location of Death Among Older Adult Americans After Falls. Gerontol Geriatr Med 2022; 8:23337214221098897. [PMID: 35559359 PMCID: PMC9087234 DOI: 10.1177/23337214221098897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: Fall-related mortality is increasing among older adults, yet
trends and changes in the location of fall-attributed deaths are unknown; additionally,
potential disparities are understudied. Methods: To assess trends/factors
associated with place of death among older adult fall deaths in the US, a cross-sectional
analysis of deaths using mortality data from 2003–2017 was performed.
Results: Most deaths occurred in hospitals, however, the proportion
decreased from 66.4% (n = 9,095) to 50.7% (n = 15,817).
The proportion occurring in nursing facilities decreased from 15.9% (n =
2175) to 15.3% (n = 4,778), while deaths at home and in hospice
facilities increased. Male, Black, Native American, and married decedents had increased
odds of hospital death. Conclusion: As fall deaths increase among older
adults, end-of-life needs of this population deserve increased attention. Research should
explore needs and preferences of older adults who experience falls and their caregivers to
reduce disparities in place of death and to ensure high quality of care is received.
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Affiliation(s)
- Sarah H. Cross
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - David M. Anderson
- Duke-Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, NC, USA
| | - Christopher E. Cox
- Division of Pulmonary Critical Care, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Krista L. Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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12
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Cralley A, Madsen H, Robinson C, Platnick C, Madison S, Trabert T, Cohen M, Cothren Burlew C, Sauaia A, Platnick KB. Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model. J Palliat Care 2022; 37:562-569. [PMID: 35138198 DOI: 10.1177/08258597221079438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE(S) Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. METHODS A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. RESULTS There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). CONCLUSIONS Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.
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Affiliation(s)
| | - Helen Madsen
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | | | | | - Angela Sauaia
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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13
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Auriemma CL, Eneanya ND, Courtright KR. COVID-19: An opportunity to rethink advance care planning conversations in acute serious illness. Palliat Med 2022; 36:216-218. [PMID: 35081836 DOI: 10.1177/02692163211072276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Catherine L Auriemma
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
| | - Nwamaka D Eneanya
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Department of Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania in Philadelphia, Pennsylvania, PA, USA
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14
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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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15
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Haines L, Wang W, Harhay M, Martin N, Halpern S, Courtright K. Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness. Am J Hosp Palliat Care 2021; 39:633-640. [PMID: 34467775 DOI: 10.1177/10499091211042303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. OBJECTIVE Describe patterns of PC delivery among a large, critically ill trauma cohort. SETTING/SUBJECTS Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. METHODS We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. RESULTS Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. CONCLUSION PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.
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Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael Harhay
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Niels Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Katherine Courtright
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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16
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Bleicher J, Place A, Schoenhals S, Luppens CL, Grudziak J, Lambert LA, McCrum ML. Drivers of Moral Distress in Surgical Intensive Care Providers: A Mixed Methods Study. J Surg Res 2021; 266:292-299. [PMID: 34038851 DOI: 10.1016/j.jss.2021.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/08/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. MATERIALS AND METHODS This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. RESULTS 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. CONCLUSIONS Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.
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Affiliation(s)
- Josh Bleicher
- Department of General Surgery, University of Utah, Salt Lake City, Utah.
| | - Aubrey Place
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Sarah Schoenhals
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Carolyn L Luppens
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Joanna Grudziak
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Laura A Lambert
- Department of General Surgery, University of Utah, Salt Lake City, Utah; Department of Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Marta L McCrum
- Department of General Surgery, University of Utah, Salt Lake City, Utah
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17
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Palliative care and aggressive interventions after falling: A Nationwide Inpatient Sample analysis. Palliat Support Care 2021; 20:101-106. [PMID: 33663643 DOI: 10.1017/s1478951521000158] [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: 01/03/2023]
Abstract
OBJECTIVE The purpose of this study is to identify whether there is an opportunity for improvement to provide palliative care services after a serious fall. We hypothesized that (1) palliative care services would be utilized in less than 10% of patients over the age of 65 who fall and (2) more than 20% of patients would receive aggressive life-sustaining treatments (LSTs) prior to death. METHODS Using the 2017 Nationwide Inpatient Sample, we identified patients who were admitted to the hospital with a fall (ICD-10 W00-W19) and were hospitalized at least two days with valid discharge data. Palliative care services (Z51.5) or LSTs (cardiopulmonary resuscitation, ventilation, reintubation, tracheostomy, feeding tube placement, vasopressors, transfusion, total parenteral nutrition, and hemodialysis) were identified with ICD-10 codes. We examined the use of palliative care or LSTs by discharge destination (home, facility, and death). Logistic regression was used to identify factors associated with palliative care. RESULTS In total, 155,241 patients were identified (median 82 years old, interquartile range 74-88); 2.5% died in hospital, and 69.4% were transferred to a facility. Palliative care occurred in 4.5% of patients, and LST occurred in 15.1%. Patients who died were significantly more likely to have had palliative care (50.1% vs. 3.4% of home or facility discharges) and were more likely to have an LST [53.0% vs. 9.8% (home) vs. 15.9% (facility)]. Palliative care was associated with both death [adjusted odds ratio (AOR) 19.84, 95% confidence interval (CI) 18.39-21.41, p < 0.001] and LST (AOR 1.36, 95% CI 1.27-1.46, p < 0.001). SIGNIFICANCE OF RESULTS Palliative care is associated with both death and LST, suggesting that physicians use palliative care as a last resort after aggressive measures have been exhausted. Patients who fall would likely benefit from the early use of palliative care to align future goals of care.
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18
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Bayuo J, Bristowe K, Harding R, Agbeko AE, Wong FKY, Agyei FB, Allotey G, Baffour PK, Agbenorku P, Hoyte-Williams PE, Agambire R. "Hanging in a balance": A qualitative study exploring clinicians' experiences of providing care at the end of life in the burn unit. Palliat Med 2021; 35:417-425. [PMID: 33198576 DOI: 10.1177/0269216320972289] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them. AIM To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines. DESIGN Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data. SETTING/PARTICIPANTS The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting. RESULTS Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners. CONCLUSIONS The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi, Eastern, Ghana.,School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, UK
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, UK
| | | | | | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi, Eastern, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Pius Agbenorku
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Ramatu Agambire
- Department of Nursing, Garden City University College, Kumasi, Ghana
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19
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den Hollander D, Albertyn R, Ambler J. Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II. Afr J Emerg Med 2020; 10:256-260. [PMID: 33299759 PMCID: PMC7700979 DOI: 10.1016/j.afjem.2020.07.011] [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] [Received: 03/12/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95–98. Mortality of burns presented to a burns unit in Africa is about 10%. Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care. There are no guidelines for palliative care in burn patients.
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Affiliation(s)
- Daan den Hollander
- Burns Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
- Corresponding author at: Red Cross Memorial Children's Hospital, Cape Town, South Africa.
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, Cape Town, South Africa
| | - Julia Ambler
- Palliative Care Practitioner, Department of Paediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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20
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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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21
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Fiorentino M, Pentakota SR, Mosenthal AC, Glass NE. The Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19. Palliat Med 2020; 34:1228-1234. [PMID: 32677509 PMCID: PMC7378312 DOI: 10.1177/0269216320940566] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has a substantial mortality risk with increased rates in the elderly. We hypothesized that age is not sufficient, and that frailty measured by preadmission Palliative Performance Scale would be a predictor of outcomes. Improved ability to identify high-risk patients will improve clinicians' ability to provide appropriate palliative care, including engaging in shared decision-making about life-sustaining therapies. AIM To evaluate whether preadmission Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19. DESIGN Retrospective observational cohort study of patients admitted with COVID-19. Palliative Performance Scale was calculated from the chart. Using logistic regression, Palliative Performance Scale was assessed as a predictor of mortality controlling for demographics, comorbidities, palliative care measures and socioeconomic status. SETTING/PARTICIPANTS Patients older than 18 years of age admitted with COVID-19 to a single urban public hospital in New Jersey, USA. RESULTS Of 443 admitted patients, we determined the Palliative Performance Scale score for 374. Overall mortality was 31% and 81% in intubated patients. In all, 36% (134) of patients had a low Palliative Performance Scale score. Compared with patients with a high score, patients with a low score were more likely to die, have do not intubate orders and be discharged to a facility. Palliative Performance Scale independently predicts mortality (odds ratio 2.89; 95% confidence interval 1.42-5.85). CONCLUSIONS Preadmission Palliative Performance Scale independently predicts mortality in patients hospitalized with COVID-19. Improved predictors of mortality can help clinicians caring for patients with COVID-19 to discuss prognosis and provide appropriate palliative care including decisions about life-sustaining therapy.
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Affiliation(s)
| | | | | | - Nina E Glass
- Rutgers New Jersey Medical School, Newark, NJ, USA
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Schockett ER, Prather CP, Benjenk I, Estroff JM. Integrating Palliative Care on an Adult Trauma Service. J Palliat Med 2020; 24:668-672. [PMID: 32960125 DOI: 10.1089/jpm.2020.0378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: In 2017, the American College of Surgeons' Trauma Quality Improvement Program adopted a Palliative Care Best Practices Guidelines that calls for early palliative care for hospitalized injured patients. Objective: To develop an educational intervention to address the palliative needs of injured patients. Design: Palliative faculty presented a three-part monthly lecture series focused on core primary palliative skills, including the components of palliative care; conducting family conferences; communication skills for complex medical decision making; pain management; and, end-of-life planning. Additionally a palliative provider joined trauma team rounds every other week to highlight opportunities for enhanced palliative assessments, identify appropriate consults, and provide just-in-time teaching. Setting: Urban, level-1 trauma center. Measurements: Surgical residents completed a survey at the beginning and end of the academic year, during which the intervention took place. All survey questions were answered with a 5-point Likert scale. Rate of palliative care consultation was also tracked. Results: There were statistically significant perceived improvements in goals-of-care discussions (initial discussion-4.30 vs. 3.52, p = 0.4; follow-up discussion-3.89 vs. 3.05, p = 0.021) and documentation (3.89 vs. 2.9, p = 0.032), incorporation of patient preferences into decision making (4.20 vs. 3.43, p = 0.04), discussion of palliative needs during rounds (4.30 vs. 2.81; p < 0.001) and care transitions (3.90 vs. 3.05, p = 0.008), respect for decisions to forgo life-sustaining treatments (4.40 vs. 3.52, p = 0.004), and identification of advance directives (4.11 vs. 3.05, p = 0.002) and surrogate decision maker (4.44 vs. 3.60, p = 0.015). The overall rate of palliative specialist consultation also increased (8.4% vs. 16.1%, p < 0.001). Conclusion: Embedding primary palliative education into usual didactic and rounding time for an inpatient trauma team is an effective way to help residents develop palliative skills and foster culture change. Educational partnerships such as this may serve as an example to other trauma programs.
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Affiliation(s)
- Erica R Schockett
- Division of Geriatrics and Palliative Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christina P Prather
- Division of Geriatrics and Palliative Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ivy Benjenk
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Hospital, Washington, DC, USA
| | - Jordan M Estroff
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Hospital, Washington, DC, USA
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Vogel R, McGraw C, Redmond D, Bourg Retired P, Dreiman C, Tanner A, Lynch N, Bar-Or D. The ACS-TQIP palliative care guidelines at two level I trauma centres: a prospective study of patient and caregiver satisfaction. BMJ Support Palliat Care 2020; 12:e120-e128. [PMID: 32581006 DOI: 10.1136/bmjspcare-2020-002229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To measure trauma patient and caregiver satisfaction before and after implementation of standardised palliative care (PC) guidelines. METHODS Prospective pre-post study at two level-I trauma centres. PC satisfaction surveys were administered prior to discharge for consented trauma patients (Family Satisfaction with Advanced Cancer Scale, Patient (FAMCARE-P13) survey)≥55 years, and their caregivers (FAMCARE survey), from 1 November 2016 to 30 November 2018. Standardised PC guidelines were implemented January 2018 and included consultations, prognostication assessments, identification of proxies, review of advanced directives and do not resuscitate orders within 24 hours of admission, while advanced goals of care, formal family meetings and spiritual care support were recommended within 72 hours of admission. Generalised linear models were used to determine whether differences in patient or caregiver satisfaction existed pre versus post implementation. RESULTS There were 572 patients (299 pre; 273 post) and 595 caregivers (334 pre; 261 post) included. Overall patient satisfaction significantly increased post implementation (82.0 vs 86.0, p=0.001). After adjustment, the implementation of the guidelines was an independent predictor of higher overall patient satisfaction (least squares mean (LSM= (83.8% (95%CI 81.2%-86.5%) vs 80.3% (77.7%-82.9%), p=0.003)). Compared with preimplementation, patient satisfaction was significantly higher post implementation in the following domains: information giving (80.9 vs 85.5, p=0.001), followed by physical care (82.2 vs 86.0, p=0.002), availability of care (83.4 vs 86.8, p=0.007) and psychosocial care (84.7 vs 87.6, p=0.04). No significant differences in caregiver satisfaction were found before or after adjustment (LSMpre: 83.1% (95%CI 80.9%-85.3%) vs. post: 82.4% (80.3%-84.5%), p=0.56)) CONCLUSIONS: Our data suggest that the implementation of PC guidelines significantly improved patient satisfaction following traumatic injury, while maintaining robust caregiver satisfaction.
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Affiliation(s)
- Rebecca Vogel
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Constance McGraw
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA.,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Diane Redmond
- Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Pamela Bourg Retired
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Chester Dreiman
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Allen Tanner
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - Neal Lynch
- Trauma Services Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA .,Trauma Research Department, Penrose Saint Francis Health Services, Colorado Springs, Colorado, USA
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Abstract
Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.
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Affiliation(s)
- Rita C. Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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25
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den Hollander D, Albertyn R, Amber J. Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review. Afr J Emerg Med 2020; 10:95-98. [PMID: 32612916 PMCID: PMC7320205 DOI: 10.1016/j.afjem.2020.01.003] [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: 02/22/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.
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Affiliation(s)
- Daan den Hollander
- Burns Unit Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, South Africa
| | - Julia Amber
- Palliative Care Practitioner, Department of Pediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Abstract
PURPOSE OF REVIEW Children with medical or surgical critical illness or injury require skillful attention to physical, emotional, psychological, and spiritual needs, whereas their families need support and guidance in facing life-threatening or life-changing events and gut-wrenching decisions. This article reviews current evidence and best practices for integrating palliative care into the pediatric intensive care unit (PICU), with a focus on surgical patients. RECENT FINDINGS Palliative care is best integrated in a tiered approach, with primary palliative care provided by the PICU and surgical providers for all patients and families, including basic symptom management, high-quality communication, and end-of-life care. Secondary and tertiary levels of care involve unit or team-based 'champions' with additional expertise, and subspecialty palliative care teams, respectively. PICU and surgical providers should be able to provide primary palliative care, to identify patients and families for whom a palliative care consult would be helpful, and should be comfortable introducing the concept of palliative care to families. SUMMARY This review provides a framework and tools to enable PICU and surgical providers to integrate palliative care best practices into patient and family care.
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27
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The Association of Time to Palliative Medicine Consultation on Geriatric Trauma Outcomes. J Trauma Nurs 2020; 27:177-184. [DOI: 10.1097/jtn.0000000000000508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fokin AA, Wycech J, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study. Am J Hosp Palliat Care 2020; 37:1068-1075. [PMID: 32319314 DOI: 10.1177/1049909120919672] [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: 12/21/2022] Open
Abstract
OBJECTIVE To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. METHODS Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019. Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). RESULTS Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC (P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). CONCLUSIONS Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA
| | | | - Susan Koff
- 535241TrustBridge Health, West Palm Beach, FL, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA.,Department of Surgery, Herbert Wertheim College of Medicine, 306688Florida International University, Miami, FL, USA
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Ay E, Weigand MA, Röhrig R, Gruss M. Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany. Anesthesiol Res Pract 2020; 2020:2356019. [PMID: 32190047 PMCID: PMC7068140 DOI: 10.1155/2020/2356019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital. METHODS Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures. RESULTS During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (. CONCLUSIONS About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.
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Affiliation(s)
- Esma Ay
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
| | - Markus. A. Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg D-69120, Germany
| | - Rainer Röhrig
- Department of Medical Informatics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marco Gruss
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
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Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care. J Surg Res 2020; 246:224-230. [DOI: 10.1016/j.jss.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 01/24/2023]
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Hwang F, Pentakota SR, McGreevy CM, Glass NE, Livingston DH, Mosenthal AC. Preinjury Palliative Performance Scale predicts functional outcomes at 6 months in older trauma patients. J Trauma Acute Care Surg 2020; 87:541-551. [PMID: 31135771 DOI: 10.1097/ta.0000000000002382] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low preinjury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients. METHODS Prospective observational study of trauma patients aged ≥55 years admitted between July 2016 and April 2018. Preinjury PPS was assessed at admission; low PPS was defined as 70 or less. Primary outcomes were mortality and functional outcomes, measured by Extended Glasgow Outcome Scale (GOSE), at discharge and 6 months. Poor functional outcomes were defined as GOSE score of 4 or less. Secondary outcomes were patient-reported outcomes at 6 months: EuroQol-5D and 36-Item Short Form Survey. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, sex, and injury severity. RESULTS In-hospital data were available for 516 patients; mean age was 70 years and median Injury Severity Score was 13. Thirty percent had low PPS. Six percent (n = 32) died in the hospital, and half of the survivors (n = 248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR, 2.6; 95% confidence interval [CI], 1.2-5.3) and poor outcomes at discharge (aRR, 2.0; 95% CI, 1.7-2.3). Six-month data were available for 176 (87%) of 203 patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low PPS patients (7% vs. 24%; p < 0.01). Low PPS predicted poor functional outcomes at 6 months (aRR, 3.1; 95% CI, 1.8-5.3) while age and Injury Severity Score did not. CONCLUSION Preinjury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low PPS patients fail to improve over time compared to high PPS patients. Preinjury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients. LEVEL OF EVIDENCE Prognostic study, Therapeutic level IV.
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Affiliation(s)
- Franchesca Hwang
- From the Department of Surgery, Rutgers New Jersey Medical School (F.H., S.R.P., N.E.G., D.H.L., A.C.M), Newark, New Jersey; and Hospital of the University of Pennsylvania (C.M.M), Philadelphia, Pennsylvania
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32
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Vogel R, McGraw C, Orlando A, Bourg P, Dreiman C, Peck L, Tanner A, Lynch N, Bar-Or D. Examining satisfaction of older adult patients and their caregivers following traumatic injury: a cross-sectional study of three level I trauma centres. BMJ Open 2019; 9:e032374. [PMID: 31719090 PMCID: PMC6858218 DOI: 10.1136/bmjopen-2019-032374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To explore satisfaction of care received by older adult patients and their primary caregivers following traumatic injury. DESIGN Prospective, cross-sectional study using the FAMCARE (Family Satisfaction with Advanced Cancer Care Scale) satisfaction surveys prior to discharge. SETTING Three level I trauma centres in Colorado from November 2016 to December 2017. PARTICIPANTS Trauma patients ≥55 years old and their primary caregivers. OUTCOME MEASURES Overall mean (SD) satisfaction, satisfaction <80% vs ≥80%, and mean satisfaction by survey conceptual structures. RESULTS Of the 319 patients and 336 caregivers included, the overall mean (SD) patient satisfaction was 81.7% (15.0%) and for caregivers was 83.6% (13.4%). The area with the highest mean for patient and caregiver satisfaction was psychosocial care (85.4% and 86.9%, respectively). Information giving was the lowest for patients (80.4%) and caregivers (80.9%). When individual items were examined, patients were significantly more satisfied with 'availability of nurses to answer questions' (84.5 (15.3) vs 87.4 (14.8), p=0.02) and significantly less satisfied with 'speed with which symptoms were treated' (80.6 (17.9) vs 84.0 (17.0), p=0.03) compared with caregivers. Patients with a history of smoking (least squares mean difference: -0.096 (-0.18 to -0.07), p<0.001) and hospital discharge destination to an outside facility of care (adjusted OR: 1.6 (1.0 to 2.4), p=0.048) were identified as independent predictors of lower overall satisfaction in generalised linear and logistic models, respectively. CONCLUSIONS Our data suggest that patients' medical history was driving both patient and caregiver satisfaction. Patient characteristics and expectations need to be considered when tailoring healthcare interventions.
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Affiliation(s)
- Rebecca Vogel
- Trauma Services Department, St. Anthony's Hospital, Lakewood, Colorado, USA
| | - Constance McGraw
- Trauma Research Department, St Anthony Hospital, Lakewood, Colorado, USA
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, USA
- Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Alessandro Orlando
- Trauma Research Department, St Anthony Hospital, Lakewood, Colorado, USA
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, USA
- Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Pamela Bourg
- Trauma Services Department, St. Anthony's Hospital, Lakewood, Colorado, USA
| | - Chester Dreiman
- Trauma Services Department, St. Anthony's Hospital, Lakewood, Colorado, USA
| | - Laura Peck
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Allen Tanner
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Neal Lynch
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research Department, St Anthony Hospital, Lakewood, Colorado, USA
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, USA
- Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado, USA
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Kim J, Engelberg RA, Downey L, Lee RY, Powelson E, Sibley J, Lober WB, Curtis JR, Khandelwal N. Predictors of Advance Care Planning Documentation in Patients With Underlying Chronic Illness Who Died of Traumatic Injury. J Pain Symptom Manage 2019; 58:857-863.e1. [PMID: 31349036 PMCID: PMC6823122 DOI: 10.1016/j.jpainsymman.2019.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Advance care planning (ACP) is difficult in the setting of a life-threatening trauma but may be equally important in this context, especially with increasing numbers of trauma victims being elderly or having multimorbidity. OBJECTIVES Identify predictors of absent ACP documentation in the electronic health records of patients with underlying chronic illness who died of traumatic injury. METHODS We used death records and electronic health records to identify decedents with chronic life-limiting illness who died of traumatic injury between 2010 and 2015 and to evaluate factors associated with documentation of living wills, durable powers of attorney, or physician orders for life-sustaining treatment. RESULTS Only 22% of decedents had ACP documentation at time of injury. Among those without preinjury ACP documentation, 4% completed ACP documentation after injury. In multipredictor analyses, patients were less likely to have ACP documentation at the time of injury if they were younger (P < 0.001), had fewer chronic illnesses (P = 0.002), and had fewer nonsurgical hospitalizations (P = 0.042) in the year before injury. Among patients without ACP documentation before injury, those with fewer postinjury nonsurgical hospitalizations were less likely to complete ACP documentation after injury (P = 0.019). CONCLUSIONS Our findings suggest that patient characteristics play an important role in the completion of ACP among patients with chronic life-limiting illness and who died from sudden severe injury. Interventions to improve ACP completion by patients with serious chronic conditions have the potential for increasing goal-concordant care in the event of traumatic injury.
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Affiliation(s)
- Justin Kim
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, New York, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Elisabeth Powelson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
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Bhangu JK, Young BT, Posillico S, Ladhani HA, Zolin SJ, Claridge JA, Ho VP. Goals of Care Discussions for the Imminently Dying Trauma Patient. J Surg Res 2019; 246:269-273. [PMID: 31614324 DOI: 10.1016/j.jss.2019.07.046] [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: 03/01/2019] [Revised: 06/19/2019] [Accepted: 07/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures. MATERIALS AND METHODS We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams. RESULTS A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001). CONCLUSIONS MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.
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Affiliation(s)
- Jasmin K Bhangu
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Brian T Young
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Sarah Posillico
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Husayn A Ladhani
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Samuel J Zolin
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffrey A Claridge
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
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Kyeremanteng K, Beckerleg W, Wan C, Vanderspank-Wright B, D'Egidio G, Sutherland S, Hartwick M, Gratton V, Sarti AJ. Survey on Barriers to Critical Care and Palliative Care Integration. Am J Hosp Palliat Care 2019; 37:108-116. [PMID: 31416329 DOI: 10.1177/1049909119867658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration. MATERIALS AND METHODS A self-administered questionnaire was developed by a multidisciplinary team. Survey items were extracted from published quality indicators in EOLC and barriers to ICU-PC integration. The study took place at 2 academic institutions. Participants consisted of physicians and nurses, ICU administrators, and allied health workers. RESULTS An overall response of 45% was achieved. Of total, 85% of the respondents were ICU nurses. The following main themes were identified: (1) There is a poor presence of PC in the ICU and 78% of respondents felt that increasing ICU-PC integration will improve quality of EOLC; (2) the main barrier to integration was unrealistic patient and/or family expectations; and (3) criteria-triggered consultation to PC was the most feasible way to achieve integration. CONCLUSION Our findings indicate that the majority of respondents perceive that the presence of PC in ICU will improve EOLC. Future quality improvement initiatives can focus on developing a set of criteria for triggering PC consults.
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Affiliation(s)
- Kwadwo Kyeremanteng
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.,Institut du Savoir Montfort, Ottawa, Ontario, Canada.,The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
| | | | - Cynthia Wan
- Faculty of Social Sciences, School of Psychology, University of Ottawa, Ontario, Canada
| | | | - Gianni D'Egidio
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada.,Division of Critical Care Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | | | - Aimee J Sarti
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
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Intensive care unit length of stay is reduced by protocolized family support intervention: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1072-1081. [PMID: 31270579 DOI: 10.1007/s00134-019-05681-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/26/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE This study aimed to elucidate the impact of protocolized family support intervention on length of stay (LOS) in the intensive care unit (ICU) through a systematic review and meta-analysis. METHODS Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and other web-based databases were referenced since inception until November 26, 2018. We included randomized-controlled trials wherein protocolized family support interventions were conducted for enhanced communication and shared medical decision-making. LOS (in days) and mortality were evaluated using a random-effects model, and adjusted LOS was estimated using a mixed-effects model. RESULTS We included seven randomized-controlled trials with 3477 patients. Protocolized family support interventions were found to significantly reduce the ICU LOS {mean difference = - 0.89 [95% confidence interval (CI) = - 1.50 to - 0.27]} and hospital LOS [mean difference = - 3.78 (95% CI = - 5.26 to - 2.29)]; the results of the mixed-effect model showed that they significantly reduced ICU LOS after adjusting for the therapeutic goal [mean difference = - 1.30 (95% CI = - 2.35 to - 0.26)], methods of measurement [mean difference = - 0.89 (95% CI = - 1.55 to - 0.22)], and timing of intervention [mean difference = - 1.05 (95% CI = - 2.05 to - 0.05)]. Similar results were found after adjusting for patients' disease severity [mean difference = - 1.21 (95% CI = - 2.03 to - 0.39)] and the trim-and-fill method [mean difference = - 0.86 (95% CI = - 1.44 to - 0.28)]. There was no difference in mortality rate in ICU and hospital between the protocolized intervention and control groups. CONCLUSIONS Protocolized family support intervention for enhanced communication and shared decision-making with the family reduced ICU LOS in critically ill patients without impacting mortality.
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Stirparo J, Barraco RD. The Role of Palliative Care in the Elderly Surgical ICU Patient. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-00286-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Singh R, Hwang F, Berlin A, Pentakota SR, Singh R, Chernock B, Mosenthal AC. Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care. J Palliat Med 2019; 22:635-643. [DOI: 10.1089/jpm.2018.0352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Roshansa Singh
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Franchesca Hwang
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ana Berlin
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ranbir Singh
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Brad Chernock
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anne C. Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. J Crit Care 2019; 51:39-45. [DOI: 10.1016/j.jcrc.2019.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
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Sviri S, Geva D, vanHeerden PV, Romain M, Rawhi H, Abutbul A, Orenbuch-Harroch E, Bentur N. Implementation of a structured communication tool improves family satisfaction and expectations in the intensive care unit. J Crit Care 2019; 51:6-12. [DOI: 10.1016/j.jcrc.2019.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/12/2019] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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Turnbull AE, Bosslet GT, Kross EK. Aligning use of intensive care with patient values in the USA: past, present, and future. THE LANCET RESPIRATORY MEDICINE 2019; 7:626-638. [PMID: 31122892 DOI: 10.1016/s2213-2600(19)30087-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Department of Epidemiology, Bloomberg School of Public Health, and Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Gabriel T Bosslet
- Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, and Charles Warren Fairbanks Center for Medical Ethics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Hanna K, Palmer J, Castanon L, Zeeshan M, Hamidi M, Kulvatunyou N, Gries L, Joseph B. Racial and Ethnic Differences in Limiting Life-Sustaining Treatment in Trauma Patients. Am J Hosp Palliat Care 2019; 36:974-979. [DOI: 10.1177/1049909119847970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Differences in health care between racial and ethnic groups exist. The literature suggests that African Americans and Hispanics prefer more aggressive treatment at the end of life. The aim of this study is to assess racial and ethnic differences in limiting life-sustaining treatment (LLST) after trauma. Study Design: We performed a 2-year (2013-2014) retrospective analysis of Trauma Quality Improvement Program database. Patients with age ≥16 and Injury Severity Score (ISS) ≥ 16 were included. Outcome measures were the incidence and the predictors of LLST. Multivariable logistic regression was performed to control for confounding variables. Results: A total of 97 024 patients were identified. Mean age was 49 (21) years, 68% were male, 68% were white, and 14% were Hispanic. The overall incidence of LLST was 7.2%. Based on race, LLST was selected as consistent with goals of care more often in white when compared to African American individuals who experience serious traumatic injury (8.0% vs 4.5%; P < .001). Based on ethnicity, LLST was more often selected in non-Hispanics (7.5% vs 5.2%, P < .001) when compared to Hispanics. On regression analysis, the independent predictors of LLST were white race (odds ratio [OR]: 2.7 [1.6–4.4], P = .02), non-Hispanic ethnicity (OR: 1.9 [1.4-4.6]; P = .03), severe head injury (OR: 1.7 [1.1-3.2]; P = .04), and ISS (OR: 3.1 [2.4-5.1]; P < .01). Conclusions: Differences exist in selecting LLST between different racial and ethnic groups in severe trauma. African Americans and Hispanics are less likely to select LLST when compared to whites and non-Hispanics. Further studies are required to analyze the factors associated with selecting LLST in African Americans and Hispanics.
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Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - James Palmer
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Lourdes Castanon
- Department of Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA
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Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee. J Trauma Acute Care Surg 2019; 86:737-743. [DOI: 10.1097/ta.0000000000002155] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Does Calculated Prognostic Estimation Lead to Different Outcomes Compared With Experience-Based Prognostication in the ICU? A Systematic Review. Crit Care Explor 2019; 1:e0004. [PMID: 32166250 DOI: 10.1097/cce.0000000000000004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Little is known about the impact of providing calculator/guideline based versus clinical experiential-based prognostic estimates to patients/caregivers in the ICU. We sought to determine whether studies have compared types of prognostic estimation in the ICU and associations with outcomes. Data Sources Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases searched were PubMed, Embase, Web of Science, and Cochrane Library. The search was run on January 4, 2016, and April 12, 2017. References for included articles were searched. Study Selection Studies meeting the following criteria were included in the analysis: communication of prognostic estimates, a comparator group, and in the adult ICU setting. Data Extraction Titles/abstracts were reviewed by two researchers. We identified 10,704 articles of which 10 met inclusion criteria. Seven of the studies included estimates obtained from calculators/guidelines and three were based on subjective estimation wherein clinicians were asked to estimate prognosis based on experience. Only the seven using calculated/guideline based estimation were used for pooled analysis. Of these, one was a randomized trial, and six were nonrandomized before/after studies. All of the studies communicated the calculated/guideline-based estimates to the clinician. Two studies involved the communication of calculated prognostic estimates to the ICU physicians for all ICU patients. Four included identification of high-risk patients based on guidelines or review of historical local data which triggered a palliative care/ethics consultation, and one study included communication to physicians about guideline based likely outcomes for neurologic recovery for patients with out-of-hospital cardiac arrest survivors. The comparator arm in all studies was usual care without protocolized prognostication. Data Synthesis Included studies were assessed for risk of bias. The most common outcomes measured were hospital mortality; do-not-resuscitate status; and medical ICU length of stay. In pooled analyses, there was an association between calculated/guideline based prognostic estimation and decreased medical ICU length of stay as well as increased do-not-resuscitate status, but no difference in hospital mortality. Conclusions Protocolized assessment of calculator/guideline based prognosis in ICU patients is associated with decreased medical ICU length of stay and increased do-not-resuscitate status but does not have a significant effect on mortality. Future studies should explore how communicating these estimates to physicians changes behaviors including communication to patients/families and whether calculator/guideline based prognostication is associated with improved patient and family rated outcomes.
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Lilley EJ, Lee KC, Scott JW, Krumrei NJ, Haider AH, Salim A, Gupta R, Cooper Z. The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge. J Trauma Acute Care Surg 2018; 85:992-998. [PMID: 29851910 PMCID: PMC6202158 DOI: 10.1097/ta.0000000000002000] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Affiliation(s)
- Elizabeth J Lilley
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts (E.J.L., K.C.L., J.W.S., A.H.H., A.S., Z.C.); Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (E.J.L., N.J.K., R.G.); Department of Surgery, University of California San Diego, La Jolla, California (K.C.L.); and Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., Z.C.)
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Lesieur O, Herbland A, Cabasson S, Hoppe MA, Guillaume F, Leloup M. Changes in limitations of life-sustaining treatments over time in a French intensive care unit: A prospective observational study. J Crit Care 2018; 47:21-29. [DOI: 10.1016/j.jcrc.2018.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/31/2023]
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A position paper: The convergence of aging and injury and the need for a Geriatric Trauma Coalition (GeriTraC). J Trauma Acute Care Surg 2018; 82:419-422. [PMID: 27893640 DOI: 10.1097/ta.0000000000001317] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Williams MT, Zimmerman E, Barry M, Trantum L, Dietrich MS, Doersam JK, Karlekar M. A Retrospective Review of Patients With Acute Stroke With and Without Palliative Care Consultations. Am J Hosp Palliat Care 2018; 36:60-64. [PMID: 29991277 DOI: 10.1177/1049909118787136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite advances in stroke care, patients continue to incur significant disability, are at risk for future events, and are inconsistently comanaged with palliative care (PC) specialty teams. The purpose of this study was to review patients with stroke admitted to our institution, comparing patients with and without PC consultation. We retrospectively reviewed medical record data of all patients with stroke admitted to our neurosciences ICU (NICU) in July 2014 to June 2015 with and without PC consultation. Review focused on stroke type, patient demographics, median days to discharge and death, and posthospitalization discharge. Of 463 patients admitted to the NICU with a stroke diagnosis, 27% (125/463) had (PC) consultation. A higher percentage of the patients with PC consult presented with hemorrhagic stroke than those without PC consult (38% vs 21%, P < .001). Patients with PC consult had longer median days to discharge and death ( P < .001) and a higher percentage of mortality (32% vs 11%). Of the 301 patients without PC consult who discharged (89.1%), 36.5% discharged to inpatient rehab while 10% discharged to a skilled nursing facility. In comparison, of the patients with PC consultation who discharged alive (41.1%), 15.7% discharged to inpatient rehab whereas 39% discharged to skilled nursing ( P < .001). The uncertainty of which patients with stroke benefit most from specialty PC is highlighted in that although sicker patients are referred to PC, a substantial portion (41%) of these patients discharge alive, of which 39.2% discharged to skilled nursing. Future research should focus on which patients with stroke would benefit from specialty PC.
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Affiliation(s)
- Molly T Williams
- 1 Division of Internal Medicine, Palliative Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eli Zimmerman
- 2 Division of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan Barry
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lindsay Trantum
- 4 Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary S Dietrich
- 5 Vanderbilt University School of Nursing, Nashville, TN, USA
| | | | - Mohana Karlekar
- 1 Division of Internal Medicine, Palliative Care, Vanderbilt University Medical Center, Nashville, TN, USA
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