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Butler CR, Wightman AG. Beyond Autonomy: Ethics of Decision Making About Treatments for Kidney Failure at the Extremes of Age. Am J Kidney Dis 2023; 82:360-367. [PMID: 37028637 PMCID: PMC10524142 DOI: 10.1053/j.ajkd.2023.01.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/18/2023] [Indexed: 04/08/2023]
Abstract
Decisions around initiating and forgoing treatments for kidney failure are complex, and contemporary approaches to medical decision making are designed to uphold patients' own preferences and values when there are multiple clinically reasonable treatment options. When patients do not have cognitive capacity to make their own decisions, these models can be adapted to support the previously expressed preferences of older adults and to promote open futures as autonomous persons for young children. Nonetheless, an autonomy-focused approach to decision making may not align with other overlapping values and needs of these groups. Dialysis profoundly shapes life experience. Values framing decisions about this treatment extend beyond independence and self-determination and vary between life stages. Patients at the extremes of age may place a strong emphasis on dignity, caring, nurturing, and joy. Models of decision making tailored to support an autonomous individual may also discount the role of family as not only surrogate decision makers but stakeholders whose lives and experience are interwoven with a patient's and will be shaped by their treatment decisions. These considerations underline a need to more flexibly incorporate a diversity of ethical frameworks to support medical decisions, especially for the very young and old, when facing complex medical decisions such as initiating or forgoing treatments for kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, School of Medicine, University of Washington, Seattle; Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle.
| | - Aaron G Wightman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
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Bullard JT, Kowalkowski M, Sparling A, Roberge J, Barkley JE. A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life. J Palliat Med 2022; 25:1835-1843. [PMID: 36137010 DOI: 10.1089/jpm.2022.0264] [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: 01/04/2023] Open
Abstract
Background: A home-based goal-concordant care model targeting patients with advanced illnesses may reduce acute care utilization and improve quality outcomes at end of life. Aim: Study aim was to determine impact of the Advanced Illness Management (AIM) program on end-of-life utilization and quality of care. Design: A retrospective observational study design using propensity score fine stratum weighting methodologies was applied to decedent patients identified for AIM enrollment/eligibility in 2018 to 2019. Setting/Participants: A total of 3859 decedents, 216 of whom were AIM enrollees, were identified from a metropolitan health system's electronic medical records (EMR) and met study eligibility criteria. Results: Compared with usual care, AIM enrollees spent more days away from acute care in the last 30, 90, and 180 days of life. Furthermore, AIM enrollees were less likely to expire in an acute care hospital. Conclusions: Enrollment in programs such as AIM should be considered for patients with advanced illnesses approaching end of life.
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Affiliation(s)
- Jarrod T Bullard
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Alica Sparling
- Health Economics, Novant Health, Charlotte, North Carolina, USA
| | - Jason Roberge
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - John E Barkley
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
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3
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Schou-Juul F, Nørgaard S, Lauridsen SMR. Ethical issues in dementia guidelines for people with dementia and informal caregivers in Denmark: A qualitative thematic synthesis. DEMENTIA 2022; 22:28-45. [PMID: 36205646 DOI: 10.1177/14713012221131856] [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
Numerous dementia-specific guidelines are offered to support people with dementia and their informal caregivers in dealing with dementia. However, the extent to which such guidelines address ethical issues and provide guidance for dealing with the issues has not yet been assessed. This study investigates the extent to which ethical issues are addressedin those guidelines, which ethical themes are considered and whatrecommendations are offered. We analysed Danish collected via onlinesearch engines and manual contact with relevant governmental, municipal and patient organisations from November 2020 to January 2021. To assess the scope of ethical issues in such guidelines, we devised an analytical framework using Beauchamp and Childress's four principles of biomedical ethics and a data-processing method inspired by systematic reviews. We collected a total 653 dementia guidelines and screened them using formal inclusion criteria, such as publication year, target group and public availability. The guidelines that satisfied these criteria were screened for content related to ethical issues and recommendations. The guidelines that addressed ethical issues were then coded in NVivo 12 and analysed using thematic text analysis. In total, 59 guidelines satisfied the formal inclusion criteria. Among these guidelines, 15 addressed ethical issues, which fell into four transversal themes: (1) being open about the disease, (2) accepting help, (3) the line between dignified behaviour and overstepping boundaries and (4) decision-making and autonomy. The ethical issues addressed in Danish dementia-specific guidelines were diverse. However, the addressed issues did not represent a comprehensive spectrum of ethical issues as identified in relevant literature, and only a few guidelines contained substantial ethical content. In conclusion, this study indicates that the need for guidance on ethical issues is not being met by dementia-specific guidelines and that further research is required to provide additional ethical guidance that benefits people with dementia and their informal caregivers.
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Affiliation(s)
- Frederik Schou-Juul
- National Institute of Public Health, 6174University of Southern Denmark, Copenhagen, Denmark
| | - Signe Nørgaard
- National Institute of Public Health, 6174University of Southern Denmark, Copenhagen, Denmark
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Palliative Care for Patients with Kidney Disease. J Clin Med 2022; 11:jcm11133923. [PMID: 35807208 PMCID: PMC9267754 DOI: 10.3390/jcm11133923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022] Open
Abstract
Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.
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Review of Religious Variables in Advance Care Planning for End-of-Life Care: Consideration of Faith as a New Construct. Am J Geriatr Psychiatry 2022; 30:747-758. [PMID: 34972634 DOI: 10.1016/j.jagp.2021.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/30/2021] [Accepted: 11/30/2021] [Indexed: 12/28/2022]
Abstract
Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.
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Clinicians’ practices and attitudes regarding advance care planning in mainland China: A multicenter cross-sectional survey. Palliat Support Care 2022; 21:477-482. [PMID: 35282846 DOI: 10.1017/s1478951522000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objectives
This study aims to explore clinicians’ practices and attitudes regarding advance care planning (ACP) in mainland China.
Methods
This study was a multicenter cross-sectional survey. Clinicians from tertiary hospitals in Beijing, Guangxi, and Inner Mongolia were invited to participate in the study. A questionnaire was formulated based on related literature to obtain information including demographic characteristics, and practices and attitudes toward ACP.
Results
The total number of participants included 285 clinicians. The data response rate was 84.57%. Most of the clinicians had an inadequate understanding of ACP. Only a few clinicians had experience in participating or witnessing an ACP or related end-of-life discussions. Among 285 clinicians, 69.82% of clinicians were willing to introduce ACP to patients. Two hundred and thirty-eight (83.51%) clinicians wanted more education on ACP. Almost all clinicians believed that patients had the right to know about their diagnosis, prognosis, and available care options. Most clinicians (82.11%) regarded that ACP was partially feasible in mainland China. If clinicians had a serious illness, almost everyone was willing to find out their true health status and decide for themselves, and 81.40% wanted to institute an ACP for themselves. The biggest barriers to the use of ACP in mainland China were cultural factors. Statistical analysis revealed that some or good understanding level (P = 0.0052) and practical experience (P = 0.0127) of ACP were associated with the positive willingness.
Significance of results
ACP is still in its infancy in mainland China. Clinicians had inadequate understanding and minimal exposure to ACP. Most clinicians recognized the value and significance of ACP and had a positive attitude toward ACP. Clinicians need to be provided with education and training to promote their ACP practices. Culturally appropriate ACP processes and documents need to be developed based on Chinese culture and Chinese needs.
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The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations. Curr Opin Anaesthesiol 2021; 34:141-144. [PMID: 33630773 DOI: 10.1097/aco.0000000000000974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW Addressing patients' Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures. RECENT FINDINGS Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive. SUMMARY Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.
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DeCourcey DD, Partin L, Revette A, Bernacki R, Wolfe J. Development of a Stakeholder Driven Serious Illness Communication Program for Advance Care Planning in Children, Adolescents, and Young Adults with Serious Illness. J Pediatr 2021; 229:247-258.e8. [PMID: 32949579 DOI: 10.1016/j.jpeds.2020.09.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/25/2020] [Accepted: 09/11/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To develop a generalizable advance care planning (ACP) intervention for children, adolescents, and young adults with serious illness using a multistage, stakeholder-driven approach. STUDY DESIGN We first convened an expert panel of multidisciplinary health care providers (HCPs), researchers, and parents to delineate key ACP intervention elements. We then adapted an existing adult guide for use in pediatrics and conducted focus groups and interviews with HCPs, parents, and seriously ill adolescents and young adults to contextualize perspectives on ACP communication and our Pediatric Serious Illness Communication Program (PediSICP). Using thematic analysis, we identified guide adaptations, preferred content, and barriers for Pedi-SICP implementation. Expert panelists then reviewed, amended and finalized intervention components. RESULTS Stakeholders (34 HCPs, 9 parents, and 7 seriously ill adolescents and young adults) participated in focus groups and interviews. Stakeholders validated and refined the guide and PediSICP intervention and identified barriers to PediSICP implementation, including the need for HCP training, competing demands, uncertainty regarding timing, and documentation of ACP discussions. CONCLUSIONS The finalized PediSICP intervention includes a structured HCP and family ACP communication occasion supported by a 3-part communication tool and bolstered by focused HCP training. We also identified strategies to ameliorate implementation barriers. Future research will determine the feasibility of the PediSICP and whether it improves care alignment with patient and family goals.
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Affiliation(s)
| | - Lindsay Partin
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Anna Revette
- Survey and Data Management Core, Dana Farber Cancer Institute, Boston, MA
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
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Veshi D, Pupe E, Venditti C, Kalemaj I, Koka E, Biring-Pani M, Ruci H. End-of-Life Decisions in Albania: The Call for an Ethical Revision. THE LIVERPOOL LAW REVIEW 2020; 41:315-330. [PMID: 32836545 PMCID: PMC7312106 DOI: 10.1007/s10991-020-09251-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
While in Western European countries, the end-of-life decisions have become a matter of public policy, this paper provides a detailed analysis of end-of-life decisions in Albania by focusing on instructional medical directives. The manuscript investigates the Albanian legal system, the documents published by the National Ethics Committee and the National Committee of Health, as the two main advisory public bodies on health issues, as well as the national medical jurisprudence and the Code of Medical Ethics. After emphasizing the importance of instructional medical directives and considering the international literature that has underlined the ethical principle of patient autonomy, this paper provides some policy suggestions. In the conclusion, this contribution highlights the importance of ad hoc rules governing instructional medical directives as well as the ethical principles and international literature as an instrument to fill the gap in the national system. In addition, particular attention is given to the application of ethical principles in end-of-life decisions in the current pandemic situation.
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Affiliation(s)
- Denard Veshi
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | - Ervin Pupe
- High Court of Albania, Rruga Deshmoret e 4 Shkurtit, Tirana, Albania
| | - Carlo Venditti
- University of Campania Luigi Vanvitelli, Via Mazzocchi, 68 - Palazzo Melzi, 81055 Santa Maria Capua Vetere, Caserta Italy
| | - Ilir Kalemaj
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | - Enkelejda Koka
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
| | | | - Hektor Ruci
- University of New York Tirana, “Kodra e Diellit”, Tirana, Albania
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Garten L, von der Hude K, Strahleck T, Krones T. Extending the Concept of Advance Care Planning to the Perinatal Period. KLINISCHE PADIATRIE 2020; 232:249-256. [PMID: 32542620 DOI: 10.1055/a-1179-0530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Easier access to prenatal diagnostic procedures led to its widespread use as a screening measure. Hence, today it is more common for life-limiting illnesses to be diagnosed during fetal life. The concept of Advance Care Planning (ACP) provides a framework for caregivers, families and their multidisciplinary teams to anticipate and plan ahead for potential future medical decisions so that the affected children are reliably treated according to their parents' individual values and wishes. In the perinatal context, ACP also has the potential to tackle the needs of unborn or newborn children with life-limiting illnesses and their families better, avoid unnecessary and burdensome measures and focus upon goals that are valuable and meaningful to both child and family.
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Affiliation(s)
- Lars Garten
- Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Strahleck
- Department of Neonatology and Neonatal Intensive Care, Klinikum Stuttgart-Olgahospital, Stuttgart, Germany
| | - Tanja Krones
- Institute of Biomedical Ethics and History of Medicine University of Zürich, University Hospital Zürich, Zürich, Switzerland
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Levoy K, Buck H, Behar-Zusman V. The Impact of Varying Levels of Advance Care Planning Engagement on Perceptions of the End-of-Life Experience Among Caregivers of Deceased Patients With Cancer. Am J Hosp Palliat Care 2020; 37:1045-1052. [PMID: 32281390 DOI: 10.1177/1049909120917899] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Advance care planning (ACP) is used to prepare patients and caregivers for future "in the moment" decisions at the end-of-life. Patients with cancer generally do not engage in all 3 components of ACP (documented living will, health-care surrogate, end-of-life discussions); however, little is known about the impact of these varying levels of ACP engagement on caregivers postdeath. OBJECTIVE To examine the relationship between varying levels of ACP engagement and caregivers' perceptions of cancer decedents' end-of-life experiences. METHODS A secondary analysis of the 2002 to 2014 waves of the Health and Retirement Study data using structural equation modeling was conducted. Five levels of ACP engagement were defined: full (discussions/documents), augmented discussions, documents only, discussions only, and no engagement. RESULTS Among the 2172 cancer death cases, the analyzed sample included 983 cases where end-of-life decisions occurred. Compared to no ACP, all levels of ACP were significantly associated with caregivers' positive perceptions of cancer decedents' end-of-life experiences (P ≤ .001), controlling for sex, race, and Hispanic ethnicity (R 2 = .21). However, the relative impact of each level of ACP engagement was not equal; full engagement (β = .61) was associated with a greater impact compared to each of the partial levels of engagement (augmented discussions [β = .33], documents only [β = .17], discussions only [β = .17]). CONCLUSION Partial ACP engagement, not just nonengagement, serves as an important clinically modifiable target to improve the end-of-life care experience among patients with cancer and the perceptions of those experiences among bereaved caregivers.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, 6572University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Harleah Buck
- 7831University of South Florida College of Nursing, Tampa, FL, USA
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Garten L, Globisch M, von der Hude K, Jäkel K, Knochel K, Krones T, Nicin T, Offermann F, Schindler M, Schneider U, Schubert B, Strahleck T. Palliative Care and Grief Counseling in Peri- and Neonatology: Recommendations From the German PaluTiN Group. Front Pediatr 2020; 8:67. [PMID: 32181234 PMCID: PMC7058113 DOI: 10.3389/fped.2020.00067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/11/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Lars Garten
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Globisch
- Department for Content and Development, German Children's Hospice Association, Olpe, Germany
| | - Kerstin von der Hude
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Jäkel
- Association of Premature and At-Risk Born Children, Regional group of Rhineland-Palatinate, Mainz, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tanja Krones
- University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zurich, Switzerland
| | - Tatjana Nicin
- Department of Obstetrics, Klinikum Hanau, Hanau, Germany
| | - Franziska Offermann
- Federal Association of Orphaned Parents and Mourning Siblings in Germany, Leipzig, Germany
| | - Monika Schindler
- Department of Neonatology and Paediatric Intensive Care, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Uwe Schneider
- Department of Obstetrics, Universitätsklinikum Jena, Jena, Germany
| | - Beatrix Schubert
- Roman-Catholic Diocese of Rottenburg-Stuttgart, Department Pastoral Care in Health Care, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Thomas Strahleck
- Department of Neonatology and Neonatal Intensive Care, Klinikum Stuttgart, Olgahospital, Stuttgart, Germany
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Stachulski F, Siegerink B, Bösel J. Dying in the Neurointensive Care Unit After Withdrawal of Life-Sustaining Therapy: Associations of Advance Directives and Health-Care Proxies With Timing and Treatment Intensity. J Intensive Care Med 2020; 36:451-458. [PMID: 32089041 DOI: 10.1177/0885066620906795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Critically ill patients require a careful approach for prognosis and decision-making. The German health legislation aims to strengthen the role of advance directives (ADs) and health-care proxies (HCPs). Their impact within a dedicated neurocritical care setting is unknown. This study aimed to assess the practice of withdrawal or withholding of life-sustaining therapy (WOLST) in a German neurointensive care unit (NICU) focusing on whether AD or HCP is associated with timing and treatment intensity. METHODS Data on patients who died after WOLST at a dedicated NICU of a German university hospital, from 2010 to 2013, were retrospectively analyzed. RESULTS Of 400 deceased patients, 310 (77.5%) died after initiation of WOLST. Among them, 68 (21.9%) were identified to have AD or HCP or both (AD + HCP). WOLST patients with AD, HCP, or AD + HCP were older than those without (median age: 77 vs 72 years, P < .001) but did not show any other distinct baseline features. There was no difference in the specific neurocritical care measures between the groups. Poisson regression analysis showed no significant difference in the probability of time-dependent WOLST initiation between those with and without AD/HCP, after adjusting for age and sex (adjusted incidence rate ratio, 1.10; 95% confidence interval, 0.94-1.28; P = .244). CONCLUSIONS In this single-center study of mainly cerebrovascular NICU patients, AD or HCP was neither associated with an earlier WOLST nor associated with a difference in treatment intensity before WOLST. Further prospective studies should assess the emerging concept of advance care planning in neurocritical care.
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Affiliation(s)
- Frank Stachulski
- Department of Neurology, German Allied Forces Hospital Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research (CSB), 14903Charité Universitätsmedizin Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, 9144University Hospital Heidelberg, Germany
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Brinkman-Stoppelenburg A, Polinder S, Olij BF, van den Berg B, Gunnink N, Hendriks MP, van der Linden YM, Nieboer D, van der Padt-Pruijsten A, Peters LA, Roggeveen B, Terheggen F, Verhage S, van der Vorst MJ, Willemen I, Vergouwe Y, van der Heide A. The association between palliative care team consultation and hospital costs for patients with advanced cancer: An observational study in 12 Dutch hospitals. Eur J Cancer Care (Engl) 2019; 29:e13198. [PMID: 31825156 PMCID: PMC7319483 DOI: 10.1111/ecc.13198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/29/2019] [Accepted: 11/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early palliative care team consultation has been shown to reduce costs of hospital care. The objective of this study was to investigate the association between palliative care team (PCT) consultation and the content and costs of hospital care in patients with advanced cancer. MATERIAL AND METHODS A prospective, observational study was conducted in 12 Dutch hospitals. Patients with advanced cancer and an estimated life expectancy of less than 1 year were included. We compared hospital care during 3 months of follow-up for patients with and without PCT involvement. Propensity score matching was used to estimate the effect of PCTs on costs of hospital care. Additionally, gamma regression models were estimated to assess predictors of hospital costs. RESULTS We included 535 patients of whom 126 received PCT consultation. Patients with PCT had a worse life expectancy (life expectancy <3 months: 62% vs. 31%, p < .01) and performance status (p < .01, e.g., WHO status higher than 2:54% vs. 28%) and more often had no more options for anti-tumour therapy (57% vs. 30%, p < .01). Hospital length of stay, use of most diagnostic procedures, medication and other therapeutic interventions were similar. The total mean hospital costs were €8,393 for patients with and €8,631 for patients without PCT consultation. Analyses using propensity scores to control for observed confounding showed no significant difference in hospital costs. CONCLUSIONS PCT consultation for patients with cancer in Dutch hospitals often occurs late in the patients' disease trajectories, which might explain why we found no effect of PCT consultation on costs of hospital care. Earlier consultation could be beneficial to patients and reduce costs of care.
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Affiliation(s)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Branko F Olij
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Nicolette Gunnink
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Mathijs P Hendriks
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Yvette M van der Linden
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Liesbeth A Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | - Brenda Roggeveen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Frederiek Terheggen
- Department of Internal Medicine, Bravis Hospital, Bergen op Zoom, The Netherlands
| | - Sylvia Verhage
- Breast Center, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Maurice J van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ingrid Willemen
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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16
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Hsieh CC, Huang HP, Tung TH, Chen IC, Beaton RD, Jane SW. The exploration of the knowledge, attitudes and practice behaviors of advanced care planning and its related predictors among Taiwanese nurses. BMC Palliat Care 2019; 18:99. [PMID: 31711482 PMCID: PMC6849307 DOI: 10.1186/s12904-019-0483-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the documented and well known patient benefits of ACP, the completion of ACP, only a minority of patients, during the advanced or EOL stage of their illnesses, receive such care. The misconceptions about ACP for healthcare providers, such as nurses, might become potential barriers to the effective implication of ACP. Also, from the transcultural perspective, it is evident essential to explore Taiwanese nurses' attitudes, knowledge, and actions of ACP. The purposes of this study were to explore the implication of ACP or hospice care for nurses caring for non-cancer chronic illness patients at a regional teaching hospital in Taiwan; and, to identify predictors of those nurses' knowledge, attitudes, and actions toward ACP. METHODS This cross-sectional study with a purposive sample of 218 nurses was conducted at a teaching hospital in southern Taiwan. Structured questionnaires were employed and data were analyzed with descriptive statistics, t-test, one-way ANOVAs, Pearson's correlation and multiple regressions. RESULTS 16.1% of Taiwanese physicians actively initiated ACP issues or conversations with patients or their family members. Nurses' attitudes toward ACP were fairly positive but their knowledge about ACP was insufficient and actions of ACP were not positively executed. The predictors of ACP-Knowledge (ACP-K) included position title, education hours and lacking of educational training. The predictors of ACP-Attitude (ACP-A) included ACP-K and "fear of patient or family member not accepting", whereas ACP-A, position title, "patients do not feel necessary" and "not sure physician's concern" were the predictors of ACP-Act. CONCLUSION Continuous education and training for nurses regarding ACP needs to be improved by taking those predictors found in this current study into account, and more studies on the nurse's role in ACP also should be further examined. TRIAL REGISTRATION KAFGH 106-012. Date of registration 1 May 2017.
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Affiliation(s)
- Chiu-Chu Hsieh
- Department of Nursing, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsiang-Ping Huang
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan, Republic of China
| | - Tao-Hsin Tung
- Department of Medical Research and Education, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China
| | - I-Chien Chen
- Department of Nursing, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Randal D Beaton
- Psychosocial & Community Health and Health Services, Schools of Nursing and Public Health, University of Washington, Seattle, USA
| | - Sui-Whi Jane
- Geriatric and Long-term Care Research Center, Graduate Institute of Nursing, Chang Gung University of Science and Technology, 261, Wen-Hua 1st Rd., Gui-Shan Dist, Tao-Yuan City, 33303, Taiwan, Republic of China. .,Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Lin-Ko, Taiwan, Republic of China.
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17
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Advance Care Planning and Parent-Reported End-of-Life Outcomes in Children, Adolescents, and Young Adults With Complex Chronic Conditions. Crit Care Med 2019; 47:101-108. [PMID: 30303834 DOI: 10.1097/ccm.0000000000003472] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES For children, adolescents, and young adults with complex chronic conditions advance care planning may be a vital component of optimal care. Advance care planning outcomes research has previously focused on seriously ill adults and adolescents with cancer where it is correlated with high-quality end-of-life care. The impact of advance care planning on end-of-life outcomes for children, adolescents, and young adults with complex chronic conditions is unknown, thus we sought to evaluate parental preferences for advance care planning and to determine whether advance care planning and assessment of specific family considerations during advance care planning were associated with differences in parent-reported end-of-life outcomes. DESIGN Cross-sectional survey. SETTING Large, tertiary care children's hospital. SUBJECTS Bereaved parents of children, adolescents, and young adults with complex chronic conditions who died between 2006 and 2015. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One-hundred fourteen parents were enrolled (54% response rate) and all parents reported that advance care planning was important, with a majority (70%) endorsing that discussions should occur early in the illness course. Parents who reported advance care planning (65%) were more likely to be prepared for their child's last days of life (adjusted odds ratio, 3.78; 95% CI, 1.33-10.77), to have the ability to plan their child's location of death (adjusted odds ratio, 2.93; 95% CI, 1.06-8.07), and to rate their child's quality of life during end-of-life as good to excellent (adjusted odds ratio, 3.59; 95% CI, 1.23-10.37). Notably, advance care planning which included specific assessment of family goals was associated with a decrease in reported child suffering at end-of-life (adjusted odds ratio, 0.23; 95% CI, 0.06-0.86) and parental decisional regret (adjusted odds ratio, 0.42; 95% CI, 0.02-0.87). CONCLUSIONS Parents of children, adolescents, and young adults with complex chronic conditions highly value advance care planning, early in the illness course. Importantly, advance care planning is associated with improved parent-reported end-of-life outcomes for this population including superior quality of life. Further studies should evaluate strategies to ensure high-quality advance care planning including specific assessment of family goals.
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Abstract
PURPOSE OF REVIEW Tattoos and medallions are examples of nonstandard do-not-resuscitate (DNR) orders that some people use to convey end-of-life wishes. These DNR orders are neither universally accepted nor understood for reasons discussed within this manuscript. RECENT FINDINGS Studies show both providers and patients confuse the meaning and implication of DNR orders. In the United States, out-of-hospital DNR orders are legislated at the state level. Most states standardized out-of-hospital DNR orders so caregivers can immediately recognize and accept the order and act on its behalf. These out-of-hospital orders are complicated by the need to be printed on paper that does not always accompany the individual. Oregon created an online system whereby individuals recorded their end-of-life wishes that medical personnel can access with an Internet connection. This system improved communication of end-of-life wishes in patients who selected comfort care only. SUMMARY To improve conveyance of an individual's wishes for end-of-life care, the authors discuss nationwide adoption of Oregon's online registry where a person's account could comprehensively document end-of-life wishes, be universally available in all healthcare institutions, and be searchable by common patient identifiers. Facial recognition software could identify unconscious patients who present without identification.
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19
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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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20
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Prater LC, Wickizer T, Bower JK, Bose-Brill S. The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice? Am J Hosp Palliat Care 2019; 36:1089-1095. [DOI: 10.1177/1049909119848987] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. Methods: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. Results: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). Conclusions: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.
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Affiliation(s)
- Laura C. Prater
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas Wickizer
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Julie K. Bower
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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21
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Simon J, Murray A, Raffin S. Facilitated Advance Care Planning: What is the Patient Experience? J Palliat Care 2019. [DOI: 10.1177/082585970802400405] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jessica Simon
- Division of Palliative Care, University of Calgary, Calgary
| | - Alison Murray
- Division of Palliative Care, University of Calgary, Calgary
| | - Shelley Raffin
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
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22
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Curtis JR, Engelberg RA, Wenrich MD, Au DH. Communication about Palliative Care for Patients with Chronic Obstructive Pulmonary Disease. J Palliat Care 2019. [DOI: 10.1177/082585970502100308] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and disability Worldwide. For many patients, maximal therapy for COPD produces only modest relief of disabling symptoms and these symptoms result in a significantly reduced quality of life. Despite the high morbidity and mortality, patients with COPD do not receive adequate palliative care. One reason these patients may receive poor quality palliative care is that patient-physician communication about palliative and EOL care is unlikely to occur. The purpose of this review is to summarize recent research regarding patient-physician communication about palliative care for patients with COPD. Understanding the barriers to this communication may be an important step to improving communication about EOL care and improving patient-centred outcomes. Two areas that may influence the quality of care received by patients with COPD are also highlighted: 1) the role of depression, a common problem in patients with COPD, in physician-patient communication; and 2) the role of advance care planning in this communication. Further research is needed to develop and test interventions that can enhance patient-physician communication about palliative and EOL care for patients with COPD, and we describe our perspective on a research agenda in each area.
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Affiliation(s)
| | | | | | - David H. Au
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA
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Pearse W, Oprescu F, Endacott J, Goodman S, Hyde M, O'Neill M. Advance care planning in the context of clinical deterioration: a systematic review of the literature. Palliat Care 2019; 12:1178224218823509. [PMID: 30718959 PMCID: PMC6348551 DOI: 10.1177/1178224218823509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
Background: A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services. Aim and design: This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined. Data sources: Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors. Results: Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral. Conclusions: The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.
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Affiliation(s)
- Wendy Pearse
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Florin Oprescu
- School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - John Endacott
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Sarah Goodman
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Mervyn Hyde
- School of Education, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Maureen O'Neill
- School of Law, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
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24
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Scheerens C, Chambaere K, Pardon K, Derom E, Van Belle S, Joos G, Pype P, Deliens L. Development of a complex intervention for early integration of palliative home care into standard care for end-stage COPD patients: A Phase 0-I study. PLoS One 2018; 13:e0203326. [PMID: 30231042 PMCID: PMC6145576 DOI: 10.1371/journal.pone.0203326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/17/2018] [Indexed: 02/06/2023] Open
Abstract
Background Research suggests that palliative home care should be integrated early into standard care for end-stage COPD patients. Patients also express the wish to be cared for and to die at home. However, a practice model for early integration of palliative home care (PHC) into standard care for end-stage COPD has not been fully developed. Aim To develop an intervention for early integration of PHC into standard care for end-stage COPD patients. Methods We conducted a Phase 0–I study according to the Medical Research Council Framework for the development of complex interventions. Phase 0 aimed to identify the inclusion criteria and key components of the intervention by way of an explorative literature search of interventions, expert consultations, and seven focus groups with general practitioners and community nurses on perceived barriers to and facilitators of early integrated PHC for COPD. In Phase 1, the intervention, its inclusion criteria and its components were developed and further refined by an expert panel and two expert opinions. Results Phase 0 resulted in identification of inclusion criteria and components from existing interventions, and barriers to and facilitators of early integration of PHC for end-stage COPD. Based on these findings, a nurse-led intervention was developed in Phase I consisting of training for PHC nurses in symptom recognition and physical therapy exercises for end-stage COPD, regular visits by PHC nurses at the patients’ homes, two information leaflets on self-management, a semi-structured protocol and follow-up plan to record the outcomes of the home visits, and integration of care by enabling collaboration and communication between home and hospital-based professional caregivers. Conclusion This Phase 0-I trial succeeded in developing a complex intervention for early integration of PHC for end-stage COPD. The use of three methods in Phase 0 gave reliable data on which to base inclusion criteria and components of the intervention. The preliminary effectiveness, feasibility and acceptability of the intervention will be subsequently tested in a Phase II study.
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Affiliation(s)
- Charlotte Scheerens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- * E-mail:
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Eric Derom
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Simon Van Belle
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Guy Joos
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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25
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Verhoeff K, Glen P, Taheri A, Min B, Tsang B, Fawcett V, Widder S. Implementation and adoption of advanced care planning in the elderly trauma patient. World J Emerg Surg 2018; 13:40. [PMID: 30202429 PMCID: PMC6127940 DOI: 10.1186/s13017-018-0201-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Geriatric trauma has high morbidity and mortality, often requiring extensive hospital stays and interventions. The number of geriatric trauma patients is also increasing significantly and accounts for a large proportion of trauma care. Specific geriatric trauma protocols exist to improve care for this complex patient population, who often have various comorbidities, pre-existing medications, and extensive injury within a trauma perspective. These guidelines for geriatric trauma care often suggest early advanced care planning (ACP) discussions and documentation to guide patient and family-centered care. Methods A provincial ACP program was implemented in April of 2012, which has since been used by our level 1 trauma center. We applied a before and after study design to assess the documentation of goals of care in elderly trauma patients following implementation of the standardized provincial ACP tool on April 1, 2012. Results Documentation of ACP in elderly major trauma patients following the implementation of this tool increased significantly from 16 to 35%. Additionally, secondary outcomes demonstrated that many more patients received goals of care documentation within 24 h of admission, and 93% of patients had goals of care documented prior to intensive care unit (ICU) admission. The number of trauma patients that were admitted to the ICU also decreased from 17 to 5%. Conclusion Early advanced care planning is crucial for geriatric trauma patients to improve patient and family-centered care. Here, we have outlined our approach with modest improvements in goals of care documentation for our geriatric population at a level 1 trauma center. We also outline the benefits and drawbacks of this approach and identify the areas for improvement to support improved patient-centered care for the injured geriatric patient. Here, we have provided a framework for others to implement and further develop. Electronic supplementary material The online version of this article (10.1186/s13017-018-0201-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K Verhoeff
- 1Faculty of Medicine and Dentistry, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - P Glen
- 2Department of Surgery, 2D4.27 Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - A Taheri
- 2Department of Surgery, 2D4.27 Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - B Min
- 1Faculty of Medicine and Dentistry, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - B Tsang
- 2Department of Surgery, 2D4.27 Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - V Fawcett
- 2Department of Surgery, 2D4.27 Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
| | - S Widder
- 2Department of Surgery, 2D4.27 Mackenzie Health Sciences Centre, University of Alberta, 8440-112 St. Edmonton, Edmonton, Alberta T6G 2B7 Canada
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26
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Hatano Y, Shikata Y, Izumi H, Kawaguchi A. Discrepancies between Reasons of Palliative Care Team Consultation and Palliative Care Team Activities. J Palliat Med 2018; 21:1278-1283. [DOI: 10.1089/jpm.2018.0086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Yutaka Hatano
- Centre for Palliative Care, Kindai University Hospital, Osaka, Japan
| | - Yuko Shikata
- Centre for Palliative Care, Kindai University Hospital, Osaka, Japan
| | - Hiroaki Izumi
- Centre for Palliative Care, Kindai University Hospital, Osaka, Japan
| | - Akinori Kawaguchi
- Centre for Palliative Care, Kindai University Hospital, Osaka, Japan
- Department of Pharmacy, Kindai University Hospital, Osaka, Japan
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27
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Vanderhaeghen B, Van Beek K, De Pril M, Bossuyt I, Menten J, Rober P. What do hospitalists experience as barriers and helpful factors for having ACP conversations? A systematic qualitative evidence synthesis. Perspect Public Health 2018; 139:97-105. [PMID: 30010486 DOI: 10.1177/1757913918786524] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Hospitalists seem to struggle with advance care planning implementation. One strategy to help them is to understand which barriers and helpful factors they may encounter. AIMS: This review aims to give an overview on what hospitalists experience as barriers and helpful factors for having advance care planning conversations. METHOD: A systematic synthesis of the qualitative literature was conducted. DATA SOURCES: A bibliographic search of English peer-reviewed publications in PubMed, Embase, CINAHL, Central, PsycINFO, and Web of Science was undertaken. RESULTS: Hospitalists report lacking communication skills which lead to difficulties with exploring values and wishes of patients, dealing with emotions of patients and families and approaching the conversation about letting a patient die. Other barriers are related to different interpretations of the concept advance care planning, cultural factors, like being lost in translation, and medicolegal factors, like fearing prosecution. Furthermore, hospitalists report that decision-making is often based on irrational convictions, and it is highly personal. Physician and patient characteristics, like moral convictions, experience, and personality play a role in the decision-making process. Hospitalists report that experience and learning from more experienced colleagues is helpful. Furthermore, efficient multidisciplinary co-operation is helping. CONCLUSION: This systematic review shows that barriers are often related to communication issues and the convictions of the involved hospitalist. However, they seem to be preventable by creating a culture where experienced professionals can be consulted, where convictions can be questioned, and where co-operation within and between organizations is encouraged. This knowledge can serve as a basis for implementation.
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Affiliation(s)
- Birgit Vanderhaeghen
- Palliative Support Team, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Karen Van Beek
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Mieke De Pril
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Inge Bossuyt
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
| | - Johan Menten
- Palliative Support Team, University Hospitals Leuven, Leuven, Belgium
- Department of Radiation-Oncology and Palliative Care, University Hospitals Leuven, Leuven, Belgium
| | - Peter Rober
- UPC KU Leuven, Leuven, Belgium
- Institute for Family and Sexuality Studies, Department of Neurosciences, School of Medicine, KU Leuven, Leuven, Belgium
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28
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Deng RL, Duan JZ, Zhang JH, Miao JR, Chen LL, Lee DT. Advance care planning for frail older people in China: A discussion paper. Nurs Ethics 2018; 26:1696-1706. [PMID: 29895229 DOI: 10.1177/0969733018779177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As the aging population, including frail older people, continues to grow in Mainland China, quality of life and end-of-life care for frail older people has attracted much attention. Advance care planning is an effective way to improve end-of-life care for people with advanced diseases, and it is widely used in developed countries; however, it is a new concept in Mainland China. The effects of advance care planning and its acceptability in Mainland China are uncertain because of its culture-sensitive characteristics. The objective of this article is to discuss the serious social issue of caring for frail older people and illustrate the possibility of implementing advance care planning in nursing homes in Mainland China through a review of relevant literature, which will focus on legislation, healthcare system engagement, public engagement, and cultural issues. Recommendations to promote and implement advance care planning include choosing nursing homes as a proper setting, establishing an ethical climate, and enhancing public awareness.
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Affiliation(s)
| | | | - Jiang-Hui Zhang
- The 5th Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Jia-Rui Miao
- Zhuhai Campus of Zunyi Medical University, China
| | - Liu-Liu Chen
- The 5th Affiliated Hospital of Zunyi Medical University, Zhuhai, China
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French EB, McCauley J, Aragon M, Bakx P, Chalkley M, Chen SH, Christensen BJ, Chuang H, Côté-Sergent A, De Nardi M, Fan E, Échevin D, Geoffard PY, Gastaldi-Ménager C, Gørtz M, Ibuka Y, Jones JB, Kallestrup-Lamb M, Karlsson M, Klein TJ, de Lagasnerie G, Michaud PC, O'Donnell O, Rice N, Skinner JS, van Doorslaer E, Ziebarth NR, Kelly E. End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported. Health Aff (Millwood) 2018; 36:1211-1217. [PMID: 28679807 DOI: 10.1377/hlthaff.2017.0174] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.
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Affiliation(s)
- Eric B French
- Eric B. French is a professor of economics at University College London; codirector of the ESRC Centre for the Microeconomic Analysis of Public Policy, Institute for Fiscal Studies; and Research Fellow at the Centre for Economic Policy Research, all in the United Kingdom
| | - Jeremy McCauley
- Jeremy McCauley is a PhD student at University College London
| | - Maria Aragon
- Maria Aragon is a research fellow in the Centre for Health Economics, University of York, in the United Kingdom
| | - Pieter Bakx
- Pieter Bakx is an assistant professor in the Institute of Health Policy and Management, Erasmus University Rotterdam, in the Netherlands
| | - Martin Chalkley
- Martin Chalkley is a professor in the Centre for Health Economics, University of York
| | - Stacey H Chen
- Stacey H. Chen is an associate professor in the National Graduate Institute for Policy Studies, in Tokyo, Japan
| | - Bent J Christensen
- Bent J. Christensen is director of the Dale T. Mortensen Center and a professor in the Department of Economics and Business Economics, Aarhus University, in Denmark
| | - Hongwei Chuang
- Hongwei Chuang is an associate professor in the Graduate School of Economics and Management at Tohoku University, in Sendai, Japan
| | - Aurelie Côté-Sergent
- Aurelie Côté-Sergent is a research professional at the Center for Interuniversity Research and Analysis of Organizations (CIRANO), in Montreal, Quebec
| | - Mariacristina De Nardi
- Mariacristina De Nardi is a professor of economics at University College London; a senior economist and research advisor at the Federal Reserve Bank of Chicago, in Illinois; a research fellow at the Centre for Economic Policy Research, in Paris, France; an international research fellow at the Institute for Fiscal Studies, in London; and a faculty research fellow at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - Elliott Fan
- Elliott Fan is an assistant professor in the Department of Economics at National Taiwan University, in Taipei
| | - Damien Échevin
- Damien Échevin is a research professor at the Université de Sherbrooke, in Quebec
| | - Pierre-Yves Geoffard
- Pierre-Yves Geoffard is a professor at the Paris School of Economics (CNRS), and a research fellow at the Centre for Economic Policy Research
| | - Christelle Gastaldi-Ménager
- Christelle Gastaldi-Ménager is deputy head of the Department of Studies on Patients and Diseases, National Health Insurance Fund for Salaried Workers, in Paris
| | - Mette Gørtz
- Mette Gørtz is an associate professor in the Department of Economics, University of Copenhagen, in Denmark
| | - Yoko Ibuka
- Yoko Ibuka is an associate professor in the Department of Economics and Management, Tohoku University
| | - John B Jones
- John B. Jones is a senior economist and research advisor at the Federal Reserve Bank of Richmond, in Virginia
| | - Malene Kallestrup-Lamb
- Malene Kallestrup-Lamb is an assistant professor in the Department of Economics and Business Economics, Aarhus University
| | - Martin Karlsson
- Martin Karlsson is a professor of economics at the University of Duisburg-Essen, Germany
| | - Tobias J Klein
- Tobias J. Klein is an associate professor in the Department of Econometrics and Operations Research, Tilburg University, in the Netherlands
| | - Grégoire de Lagasnerie
- Grégoire de Lagasnerie is a health economist at the National Health Insurance Fund for Salaried Workers
| | - Pierre-Carl Michaud
- Pierre-Carl Michaud is a professor in the Department of Applied Economics, HEC Montreal
| | - Owen O'Donnell
- Owen O'Donnell is a professor in the Erasmus School of Economics, Erasmus University Rotterdam, and at the University of Macedonia, in Thessaloniki, Greece
| | - Nigel Rice
- Nigel Rice is a professor in the Centre for Health Economics and Department of Economics and Related Studies, University of York
| | - Jonathan S Skinner
- Jonathan S. Skinner is the James O. Freedman Presidential Professor of Economics in the Department of Economics at Dartmouth and a professor in the Department of Family and Community Medicine, Geisel School of Medicine, and at the Dartmouth Institute for Health Policy and Clinical Practice, all in Hanover, New Hampshire
| | - Eddy van Doorslaer
- Eddy van Doorslaer is a professor in the Institute of Health Policy and Management, Erasmus School of Economics, Erasmus University Rotterdam
| | - Nicolas R Ziebarth
- Nicolas R. Ziebarth is an assistant professor in the Department of Policy Analysis and Management, Cornell University, in Ithaca, New York
| | - Elaine Kelly
- Elaine Kelly is a senior research economist at the Institute for Fiscal Studies, in London
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Koss C. Encounters With Health-Care Providers and Advance Directive Completion by Older Adults. J Palliat Care 2018; 33:178-181. [PMID: 29651900 DOI: 10.1177/0825859718769099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Patient Self-Determination Act (PSDA) requires hospitals, home health agencies, nursing homes, and hospice providers to offer new patients information about advance directives. There is little evidence regarding whether encounters with these health-care providers prompt advance directive completion by patients. OBJECTIVE To examine whether encounters with various types of health-care providers were associated with higher odds of completing advance directives by older patients. METHOD Logistic regression using longitudinal data from the 2012 and 2014 waves of the Health and Retirement Study. Participants were 3752 US adults aged 65 and older who reported not possessing advance directives in 2012. Advance directive was defined as a living will and/or durable power of attorney for health care. Four binary variables measured whether participants had spent at least 1 night in a hospital, underwent outpatient surgery, received home health or hospice care, or spent at least one night in a nursing home between 2012 and 2014. RESULTS Older adults who received hospital, nursing home, or home health/hospice care were more likely to complete advance directives. Outpatient surgery was not associated with advance directive completion. CONCLUSIONS Older adults with no advance directive in 2012 who encountered health-care providers covered by the PSDA were more likely to have advance directives by 2014. The exception was outpatient surgery which is frequently provided in freestanding surgery centers not subject to PSDA mandates. It may be time to consider amending the PSDA to cover freestanding surgery centers.
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Affiliation(s)
- Catheryn Koss
- 1 Department of Gerontology, California State University, Sacramento, CA, USA
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31
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Chen WL, Chen CM, Kung SC, Wang CM, Lai CC, Chao CM. The outcomes and prognostic factors of acute respiratory failure in the patients 90 years old and over. Oncotarget 2018; 9:7197-7203. [PMID: 29467961 PMCID: PMC5805547 DOI: 10.18632/oncotarget.24051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 12/24/2017] [Indexed: 11/26/2022] Open
Abstract
This retrospective cohort study investigated the outcomes and prognostic factors in nonagenarians (patients 90 years old or older) with acute respiratory failure. Between 2006 and 2016, all nonagenarians with acute respiratory failure requiring invasive mechanical ventilation (MV) were enrolled. Outcomes including in-hospital mortality and ventilator dependency were measured. A total of 173 nonagenarians with acute respiratory failure were admitted to the intensive care unit (ICU). A total of 56 patients died during the hospital stay and the rate of in-hospital mortality was 32.4%. Patients with higher APACHE (Acute Physiology and Chronic Health Evaluation) II scores (adjusted odds ratio [OR], 5.91; 95 % CI, 1.55-22.45; p = 0.009, APACHE II scores ≥ 25 vs APACHE II scores < 15), use of vasoactive agent (adjust OR, 2.67; 95% CI, 1.12-6.37; p = 0.03) and more organ dysfunction (adjusted OR, 11.13; 95% CI, 3.38-36.36, p < 0.001; ≥ 3 organ dysfunction vs ≤ 1 organ dysfunction) were more likely to die. Among the 117 survivors, 25 (21.4%) patients became dependent on MV. Female gender (adjusted OR, 3.53; 95% CI, 1.16-10.76, p = 0.027) and poor consciousness level (adjusted OR, 4.98; 95% CI, 1.41-17.58, p = 0.013) were associated with MV dependency. In conclusion, the mortality rate of nonagenarians with acute respiratory failure was high, especially for those with higher APACHE II scores or more organ dysfunction.
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Affiliation(s)
- Wan-Ling Chen
- Department of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan
| | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Recreation and Health-Care Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Shu-Chen Kung
- Department of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Min Wang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
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33
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Curtis JR, Sathitratanacheewin S, Starks H, Lee RY, Kross EK, Downey L, Sibley J, Lober W, Loggers ET, Fausto JA, Lindvall C, Engelberg RA. Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges. J Palliat Med 2017; 21:S52-S60. [PMID: 29182487 DOI: 10.1089/jpm.2017.0542] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. METHODS In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. RESULTS In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of community- and population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. DISCUSSION Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.
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Affiliation(s)
- J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Seelwan Sathitratanacheewin
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Robert Y Lee
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Erin K Kross
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Seattle Cancer Care Alliance , Seattle, Washington.,7 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Charlotta Lindvall
- 8 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
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Yadav KN, Gabler NB, Cooney E, Kent S, Kim J, Herbst N, Mante A, Halpern SD, Courtright KR. Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Health Aff (Millwood) 2017; 36:1244-1251. [DOI: 10.1377/hlthaff.2017.0175] [Citation(s) in RCA: 311] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kuldeep N. Yadav
- Kuldeep N. Yadav is a research coordinator in the Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, in Philadelphia
| | - Nicole B. Gabler
- Nicole B. Gabler is a senior research investigator in the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
| | - Elizabeth Cooney
- Elizabeth Cooney is director of research operations of the Palliative and Advanced Illness Research Center and assistant director of the Fostering Improvement in End-of-Life Decision Science Program, Perelman School of Medicine, University of Pennsylvania
| | - Saida Kent
- Saida Kent is a medical student at the University of Kentucky College of Medicine, in Lexington, and a research assistant in the Palliative and Advanced Illness Research Center, University of Pennsylvania
| | - Jennifer Kim
- Jennifer Kim is a medical student at Thomas Jefferson University, in Philadelphia
| | - Nicole Herbst
- Nicole Herbst is a medical resident at Boston Medical Center, in Massachusetts
| | - Adjoa Mante
- Adjoa Mante is an undergraduate student at Princeton University, in New Jersey
| | - Scott D. Halpern
- Scott D. Halpern is director of the Palliative and Advanced Illness Research Center, director of the Fostering Improvement in End-of-Life Decision Science Program, and an associate professor of medicine, epidemiology, and medical ethics and health policy, all at the Perelman School of Medicine, University of Pennsylvania
| | - Katherine R. Courtright
- Katherine R. Courtright ( ) is an instructor of medicine in the Division of Pulmonary, Allergy, and Critical Care, the Palliative and Advanced Illness Research Center, and the Fostering Improvement in End-of-Life Decision Science Program, all at the Perelman School of Medicine, University of Pennsylvania
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Martin RS, Hayes BJ, Hutchinson A, Yates P, Lim WK. Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial. BMJ Open 2017; 7:e013909. [PMID: 28283490 PMCID: PMC5353337 DOI: 10.1136/bmjopen-2016-013909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) 'Goals of Patient Care' (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration. METHODS AND ANALYSIS This is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration. DISSEMINATION The results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area. TRIAL REGISTRATION NUMBER ACTRN12615000298516, Results.
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Affiliation(s)
- Ruth S Martin
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anastasia Hutchinson
- Northern Health, Epping, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
| | - Paul Yates
- University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Wen Kwang Lim
- Northern Health, Epping, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Health, Melbourne, Victoria, Australia
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36
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Kurella Tamura M, Montez-Rath ME, Hall YN, Katz R, O’Hare AM. Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. Clin J Am Soc Nephrol 2017; 12:435-442. [PMID: 28057703 PMCID: PMC5338713 DOI: 10.2215/cjn.07510716] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/28/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the relation between the content of advance directives and downstream treatment decisions among patients receiving maintenance dialysis. In this study, we determined the prevalence of advance directives specifying treatment limitations and/or surrogate decision-makers in the last year of life and their association with end-of-life care among nursing home residents. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using national data from 2006 to 2007, we compared the content of advance directives among 30,716 nursing home residents receiving dialysis to 30,825 nursing home residents with other serious illnesses during the year before death. Among patients receiving dialysis, we linked the content of advance directives to Medicare claims to ascertain site of death and treatment intensity in the last month of life. RESULTS In the last year of life, 36% of nursing home residents receiving dialysis had a treatment-limiting directive, 22% had a surrogate decision-maker, and 13% had both in adjusted analyses. These estimates were 13%-27%, 5%-11%, and 6%-13% lower, respectively, than for decedents with other serious illnesses. For patients receiving dialysis who had both a treatment-limiting directive and surrogate decision-maker, the adjusted frequency of hospitalization, intensive care unit admission, intensive procedures, and inpatient death were lower by 13%, 17%, 13%, and 14%, respectively, and hospice use and dialysis discontinuation were 5% and 7% higher compared with patients receiving dialysis lacking both components. CONCLUSIONS Among nursing home residents receiving dialysis, treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths, but were in place much less often than for nursing home residents with other serious illnesses.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Maria E. Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Yoshio N. Hall
- Department of Medicine, Group Health Cooperative, Seattle, Washington
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and
| | - Ronit Katz
- Department of Medicine, Group Health Cooperative, Seattle, Washington
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and
| | - Ann M. O’Hare
- Department of Medicine, Group Health Cooperative, Seattle, Washington
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; and
- Department of Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
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Carson RC, Bernacki R. Is the End in Sight for the "Don't Ask, Don't Tell" Approach to Advance Care Planning? Clin J Am Soc Nephrol 2017; 12:380-381. [PMID: 28232404 PMCID: PMC5338698 DOI: 10.2215/cjn.00980117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel C Carson
- Island Health, Nanaimo Regional Hospital, Nanaimo, British Columbia, Canada; and
| | - Rachelle Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Ariadne Labs, Brigham and Women's Hospital & Harvard School of Public Health, Boston, Massachusetts
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Lum HD, Dukes J, Church S, Abbott J, Youngwerth JM. Teaching Medical Students About "The Conversation": An Interactive Value-Based Advance Care Planning Session. Am J Hosp Palliat Care 2017; 35:324-329. [PMID: 28273761 DOI: 10.1177/1049909117696245] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) promotes care consistent with patient wishes. Medical education should teach how to initiate value-based ACP conversations. OBJECTIVE To develop and evaluate an ACP educational session to teach medical students a value-based ACP process and to encourage students to take personal ACP action steps. DESIGN Groups of third-year medical students participated in a 75-minute session using personal reflection and discussion framed by The Conversation Starter Kit. The Conversation Project is a free resource designed to help individuals and families express their wishes for end-of-life care. SETTING AND PARTICIPANTS One hundred twenty-seven US third-year medical students participated in the session. MEASUREMENTS Student evaluations immediately after the session and 1 month later via electronic survey. RESULTS More than 90% of students positively evaluated the educational value of the session, including rating highly the opportunities to reflect on their own ACP and to use The Conversation Starter Kit. Many students (65%) reported prior ACP conversations. After the session, 73% reported plans to discuss ACP, 91% had thought about preferences for future medical care, and 39% had chosen a medical decision maker. Only a minority had completed an advance directive (14%) or talked with their health-care provider (1%). One month later, there was no evidence that the session increased students' actions regarding these same ACP action steps. CONCLUSION A value-based ACP educational session using The Conversation Starter Kit successfully engaged medical students in learning about ACP conversations, both professionally and personally. This session may help students initiate conversations for themselves and their patients.
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Affiliation(s)
- Hillary D Lum
- 1 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,2 Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Joanna Dukes
- 1 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Skotti Church
- 1 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,2 Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Jean Abbott
- 3 Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Jean M Youngwerth
- 1 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Dharmarajan K, Hsieh A, Dreyer RP, Welsh J, Qin L, Krumholz HM. Relationship Between Age and Trajectories of Rehospitalization Risk in Older Adults. J Am Geriatr Soc 2016; 65:421-426. [PMID: 27874977 DOI: 10.1111/jgs.14583] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To characterize the magnitude and duration of risk of rehospitalization according to age after hospitalization for heart failure (HF), acute myocardial infarction (AMI), or pneumonia. DESIGN Retrospective cohort study. SETTING U.S. hospitals (n = 4,767). PARTICIPANTS All Medicare fee-for-service beneficiaries aged 65 and older surviving hospitalization for HF, AMI, or pneumonia between October 2012 and December 2013. MEASUREMENTS Daily risk of first rehospitalization for 1 year after hospital discharge was calculated according to age category (65-74, 75-84, ≥85) after adjustment for sex, race, comorbidities, and median ZIP code income. Time required for adjusted rehospitalization risk to decline 50% from maximum value after discharge, time required for adjusted risk to approach a plateau period of minimal day-to-day change, and degree to which adjusted risk was higher in recently hospitalized individuals than in the general elderly population were identified. RESULTS There were 414,720 hospitalizations for HF, 177,752 for AMI, and 568,304 for pneumonia. The adjusted risk of rehospitalization declined with increasing age after HF hospitalization (P < .001), rose with increasing age after AMI hospitalization (P < .001), and was slightly lower with increasing age after pneumonia hospitalization (P = .002). Adjusted risks of rehospitalization were high beyond 30 days after hospitalization for all ages. CONCLUSION Although older age has heterogeneous relationships with rehospitalization risk, risk of readmission remains high for an extended time after discharge regardless of age or admitting condition. Condition-specific data on risk can be used to guide discussions on advanced care planning and strategies for longitudinal follow-up after hospitalization.
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Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Angela Hsieh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Rachel P Dreyer
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jack Welsh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Health Policy and Administration, School of Public Health, Yale University, New Haven, Connecticut.,Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Victoria K, Patel S. The Palliative Care Information Act and Access to Palliative Care in Terminally ill Patients: A Retrospective Study. Indian J Palliat Care 2016; 22:427-431. [PMID: 27803564 PMCID: PMC5072234 DOI: 10.4103/0973-1075.191774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Studies have shown that over 50% of end-of-life discussions take place for the first time in the hospital and that terminally ill patients often have unrealistic views regarding the possible scope of treatment. The Palliative Care information Act (PCIA) was passed in an attempt to address the lack of access for terminally ill patients to palliative care services. A multi-database systematic review was performed on published studies from 2010 to present, and there were none found measuring the effectiveness of the PCIA. Objectives: We aimed to study the effect of the PCIA on access to palliative care services. Methods: We conducted a retrospective chart review of all terminally ill patients who died at Kingsbrook Jewish Medical Center from January 2010 to August 2013 in relation to passing of the PCIA. Results: Prelaw (prior to the law passing), 12.3% of the terminal patients received palliative care consults, 25% during the transition period (time between passing of law and when it came into effect) and 37.7% postlaw (after coming into effect) (P < 0.001). Conclusions: Legislation can have a significant effect on terminally ill patient's access to palliative care services and can change the culture of a hospital to be more pro-palliative for the appropriate populations.
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Affiliation(s)
- Kitty Victoria
- Department of Medicine, New York Methodist Hospital, Brooklyn, New York, USA
| | - Sarita Patel
- Department of Palliative Care Services, Kingsbrook Jewish Hospital, Brooklyn, New York, USA
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Cai S, Miller SC, Mukamel DB. Racial Differences in Hospitalizations of Dying Medicare-Medicaid Dually Eligible Nursing Home Residents. J Am Geriatr Soc 2016; 64:1798-805. [PMID: 27549337 PMCID: PMC5026884 DOI: 10.1111/jgs.14284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents. DESIGN National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status. SETTING Nursing homes in the United States. PARTICIPANTS Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948). MEASUREMENTS Racial difference in EOL hospitalizations from a NH. RESULTS End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status. CONCLUSION Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.
| | - Susan C Miller
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, Providence, Rhode Island
| | - Dana B Mukamel
- Division of General Internal Medicine, Department of Medicine and iTEQC Research Program, University of California at Irvine, Irvine, California
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Meyers DE, Goodlin SJ. End-of-Life Decisions and Palliative Care in Advanced Heart Failure. Can J Cardiol 2016; 32:1148-56. [DOI: 10.1016/j.cjca.2016.04.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/14/2016] [Accepted: 04/25/2016] [Indexed: 12/21/2022] Open
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Hildén HM, Louhiala P, Honkasalo ML, Palo J. Finnish Nurses’ Views on End-of-Life Discussions and a Comparison with Physicians’ Views. Nurs Ethics 2016; 11:165-78. [PMID: 15030024 DOI: 10.1191/0969733004ne681oa] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study investigated Finnish nurses’ experiences and views on end-of-life decision making and compared them with physicians’ views. For this purpose, a questionnaire was sent to 800 nurses, of which 51% responded. Most of the nurses had a positive attitude towards and respect for living wills, more often than physicians. Most also believed that a will had an effect on decision making. Almost all of the nurses considered it their responsibility to talk to physicians about respecting living wills. Do-not-resuscitate (DNR) orders were often interpreted to imply partial or complete palliative (symptom-orientated) care, which may cause confusion. Half of the nurses reported that a DNR decision was discussed always or often with a patient who was able to communicate; physicians were more positive in this respect. Surprisingly, many nurses (44%) stated that active treatment continued too long. Two-thirds thought that their opinions were taken into account sufficiently, even though only half believed that, in general, they had some impact.
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Patel MI, Bhattacharya J, Asch SM, Kahn J. Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer. Am J Hosp Palliat Care 2016; 33:742-7. [DOI: 10.1177/1049909115595216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer. Methods: We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral. Results: Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC. Discussion: We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jay Bhattacharya
- Health Policy & Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M. Asch
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
| | - James Kahn
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, USA
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McDonald DD, Deloge JA, Joslin N, Petow WA, Severson JS, Votino R, Shea MD, Drenga JML, Brennan MT, Moran AB, Del Signore E. Communicating End-of-Life Preferences. West J Nurs Res 2016; 25:652-66; discussion 667-75. [PMID: 14528616 DOI: 10.1177/0193945903254062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this survey was to explore how adults communicate their end-of-life preferences. Face-to-face interviews were conducted with 119 community-dwelling adults who had previously engaged in conversations about their end-of-life preferences. Factors that made it easier to initiate the discussion included having personal experience with illness or death (24.4%), being straightforward (24.4%), or having someone else facilitate the discussion (11.8%). Most described vague end-of-life preferences such as not wanting any machines (41.2%) or heroics (34.5%). Although 22.7% reported using a living will to make their preferences clear, only 5.9% mentioned repeating or reinforcing their preferences. In all, 21% had discussed their end-of-life preferences with their physicians. These findings show discussions about end-of-life preferences frequently lack the clarity and detail needed by significant others and health care providers to honor the preferences. Routine dialogue with health care providers and significant others about end-of-life preferences might provide greater clarity and comfort.
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Malhotra C, Sim DKL, Jaufeerally F, Vikas NN, Sim GWC, Tan BC, Ng CSH, Tho PL, Lim J, Chuang CYT, Fong FHM, Liu J, Finkelstein EA. Impact of advance care planning on the care of patients with heart failure: study protocol for a randomized controlled trial. Trials 2016; 17:285. [PMID: 27287330 PMCID: PMC4902978 DOI: 10.1186/s13063-016-1414-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/27/2016] [Indexed: 11/10/2022] Open
Abstract
Background Despite the promise and popularity of advance care planning, there is insufficient evidence that advance care planning helps patients to meet their end-of-life care preferences, especially in Asian settings. Thus, the proposed study aims to assess whether patients with advanced heart failure who are receiving advance care planning have a greater likelihood of receiving end-of-life care consistent with their preferences compared to patients receiving usual care. Secondary objectives are to compare differences in health care expenditures, quality of life, anxiety and depression, understanding of own illness, participation in decision-making and concordance with their caregiver’s preferences for end-of-life care, between patients with advanced heart failure receiving advance care planning and usual care. Methods/design This is a two-arm randomized controlled trial of advance care planning versus usual care (control) conducted at two institutions in Singapore. Two hundred and eighty-two patients with advanced heart failure (n = 94 in the advance care planning arm; n = 188 in the control arm receiving usual care) will be recruited from these centers and followed for 1 year or until they die, whichever is earlier. Additionally, the study will include up to one caregiver per patient enrolled. Discussion If advance care planning is proven to be effective, the results will help to promote its uptake among health care providers and patients both within Singapore and in other countries. Trial registration NCT02299180. Registered on 18 November 2014.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore. .,Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | | | | | | | | | - Boon Cheng Tan
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Clarice Shu Hwa Ng
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Pei Leng Tho
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Jingfen Lim
- Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | | | | | - Joy Liu
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
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Lifshitz G, Cohen MJ, Shmilovitz H, Brezis M, Lahad A, Ben-Yehuda A. Physician-facilitated designation of proxy decision-makers: family physician perceptions. Isr J Health Policy Res 2016; 5:6. [PMID: 27134719 PMCID: PMC4851817 DOI: 10.1186/s13584-016-0059-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/05/2016] [Indexed: 11/16/2022] Open
Abstract
Background Among the challenges encountered during the care of patients at the end-of-life (EOL), eliciting preferences of patients with whom there is no ability to communicate is common and stressful for all those concerned and charged with patient care. Legal facilities available include patient delegation of proxy decision-makers (PDM) prior to communication incapacity. We sought to estimate family physician awareness and attitude with regard to these aspects of patient care. Methods A telephone survey of family physicians in the Jerusalem, Israel, district using a standard questionnaire. Results 74 family physicians responded to the survey. The response rate was 42 % and the cooperation rate was 66 %. Most of the respondents, (64 %), reported knowing that the PDM delegation facility exists, though only 24 % claimed to have suggested to their patients that they consider this option. Approximately three-quarters, (78 %), treat patients with whom they discussed other aspects of severe disease, disability or EOL. None of the physicians working predominantly with religiously observant groups reported suggesting PDM delegation. Conclusions There is an apparent gap between family physician knowledge and their performance to empower the persistence of patient autonomy, should communication ability cease. System-wide interventions to increase EOL communication skills, starting at medical school and henceforth, are necessary in order to promote better EOL care and meaningful resource use.
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Affiliation(s)
- Gideon Lifshitz
- Clalit Health Services, Jerusalem district, Jerusalem, Israel
| | - Matan J Cohen
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Center for Quality and Clinical Safety, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hila Shmilovitz
- Center for Quality and Clinical Safety, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mayer Brezis
- Center for Quality and Clinical Safety, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amnon Lahad
- Clalit Health Services, Jerusalem district, Jerusalem, Israel.,Department of Family Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Arie Ben-Yehuda
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Velter C, Cribier B, Goldwasser F, Vinant P. [Advance directives in dermato-oncology: The current situation and future prospects]. Ann Dermatol Venereol 2016; 143:505-11. [PMID: 27080821 DOI: 10.1016/j.annder.2016.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/26/2015] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patient information and advance directives (AD) are described in the French laws of 4 March 2002 and 22 April 2005, which concern the decisions of subjects regarding end-of-life treatment. At present, practitioners rarely seek the opinion of patients on this matter. The Claeys-Leonetti law requires doctors to identify any advance directives by patients, which are binding upon medical staff. The present study sought to analyse the extent of application of the laws of 2002 and 2005 and to collect the observations of clinicians in dermato-oncology regarding the new legislation. METHODS We contacted members of the French dermato-oncology group by email and asked them to assess their practices with regard to information provision, patient surrogates and advance directives. RESULTS To 111 requests we received 34 replies from hospital dermatologists, i.e. a response rate of 31 %. In all, 85 % of clinicians informed patients with metastasis that their disease was incurable, and 94 % stated that they have procedures in place concerning the appointment of a patient surrogate. One third of respondents reported having a procedure in place for provision of information or collection of advance directives. According to 91 % of clinicians, the binding nature of advance directives did not constitute any loss of chance for the patient in question; 59 % felt that the new law would affect their practices, but of these, paradoxically, 60 % felt that this would have no impact on their therapeutic decision-making. In all, 26 clinicians (76.5 %) did not intend to modify their decision-making process. CONCLUSION The law of 2002 is generally better known than that of 2005. Dermato-oncologists are not aware of the practical consequences of the new binding nature of advance directives with regard to the doctor-patient relationship and the actual decision-making process.
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Affiliation(s)
- C Velter
- Clinique dermatologique, faculté de médecine, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France; Laboratoire d'éthique médicale, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France.
| | - B Cribier
- Clinique dermatologique, faculté de médecine, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - F Goldwasser
- Service de cancérologie, hôpital Cochin, université Paris Descartes, Assistance publique-Hôpitaux de Paris (AP-HP), 123, boulevard de Port-Royal, 75014 Paris, France
| | - P Vinant
- Service de médecine palliative, hôpital Cochin, université Paris Descartes, AP-HP, 123, boulevard de Port-Royal, 75014 Paris, France
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Martin RS, Hayes B, Gregorevic K, Lim WK. The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2016; 17:284-93. [DOI: 10.1016/j.jamda.2015.12.017] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
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50
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Sullivan SC, Garner KK, Dubbert P. Recruitment for an Advance Care Planning Study: Lessons Learned. J Am Geriatr Soc 2016; 64:666-7. [PMID: 27000352 DOI: 10.1111/jgs.13984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sheila Cox Sullivan
- Geriatric Research, Education and Clinical Center, Veterans Integrated Service Network 16, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Kimberly K Garner
- Geriatric Research, Education and Clinical Center, Veterans Integrated Service Network 16, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Patricia Dubbert
- Geriatric Research, Education and Clinical Center, Veterans Integrated Service Network 16, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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