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Vitous CA, Shabet C, Ferguson C, Edwards S, Duby A, Suwanabol PA. Family perspectives on end-of-life care after surgery: A qualitative analysis of the veteran affairs bereaved family surveys. Am J Surg 2024; 233:11-15. [PMID: 38168605 DOI: 10.1016/j.amjsurg.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Using open-text responses from the Bereaved Family Survey (BFS), we sought to explore Veteran family experiences on end-of-life care after surgery. METHODS We evaluated 936 open-text responses for all decedents who underwent any high-risk surgical procedure across 124 Veterans Affairs facilities between 2010 and 2019. Data were analyzed using thematic analysis. RESULTS Respondents expressed a belief in the decedent's unnecessary pain, expressing distrust in the treatment decisions of the care team. Limited communication regarding the severity of disease or risks of surgery caused conflicting and unresolved narratives regarding the cause or timing of death. Respondents described feelings of disempowerment when they were not involved in decision-making and when their wishes were not respected. CONCLUSIONS Timely and sensitive conversations, including acknowledging uncertainty in outcomes, may ensure a more positive experience for bereaved families.
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Affiliation(s)
- C Ann Vitous
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States.
| | | | - Cara Ferguson
- University of Michigan Medical School, Ann Arbor, United States
| | - Sydney Edwards
- University of Michigan Medical School, Ann Arbor, United States
| | - Ashley Duby
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
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Piscator E, Djarv T. To withhold resuscitation - The Swedish system's rules and challenges. Resusc Plus 2023; 16:100501. [PMID: 38026137 PMCID: PMC10665955 DOI: 10.1016/j.resplu.2023.100501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision "Do-Not-Attempt-Cardio-Pulmonary-Resuscitation" (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6-13% of patients dying in Swedish hospitals. According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will. Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions. We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.
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Affiliation(s)
- Eva Piscator
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Emergency Department, Capio Sankt Görans Hospital, Stockholm, Sweden
| | - Therese Djarv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Emergency Department, Karolinska University Hospital, Stockholm, Sweden
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Santos FCD, Snigurska UA, Keenan GM, Lucero RJ, Modave F. Clinical Decision Support Systems for Palliative Care Management: A Scoping Review. J Pain Symptom Manage 2023; 66:e205-e218. [PMID: 36933748 PMCID: PMC11162595 DOI: 10.1016/j.jpainsymman.2023.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
CONTEXT With the expansion of palliative care services in clinical settings, clinical decision support systems (CDSSs) have become increasingly crucial for assisting bedside nurses and other clinicians in improving the quality of care to patients with life-limiting health conditions. OBJECTIVES To characterize palliative care CDSSs and explore end-users' actions taken, adherence recommendations, and clinical decision time. METHODS The CINAHL, Embase, and PubMed databases were searched from inception to September 2022. The review was developed following the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. Qualified studies were described in tables and assessed the level of evidence. RESULTS A total of 284 abstracts were screened, and 12 studies comprised the final sample. The CDSSs selected focused on identifying patients who could benefit from palliative care based on their health status, making referrals to palliative care services, and managing medications and symptom control. Despite the variability of palliative CDSSs, all studies reported that CDSSs assisted clinicians in becoming more informed about palliative care options leading to better decisions and improved patient outcomes. Seven studies explored the impact of CDSSs on end-user adherence. Three studies revealed high adherence to recommendations while four had low adherence. Lack of feature customization and trust in guideline-based in the initial stages of feasibility and usability testing were evident, limiting the usefulness for nurses and other clinicians. CONCLUSION This study demonstrated that implementing palliative care CDSSs can assist nurses and other clinicians in improving the quality of care for palliative patients. The studies' different methodological approaches and variations in palliative CDSSs made it challenging to compare and validate the applicability under which CDSSs are effective. Further research utilizing rigorous methods to evaluate the impact of clinical decision support features and guideline-based actions on clinicians' adherence and efficiency is recommended.
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Affiliation(s)
- Fabiana Cristina Dos Santos
- Department of Family, Community, and Health Systems Science (F.C.D.S, U.A.S., G.M.K.), College of Nursing, University of Florida, Gainesville, Florida, USA.
| | - Urszula A Snigurska
- Department of Family, Community, and Health Systems Science (F.C.D.S, U.A.S., G.M.K.), College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Gail M Keenan
- Department of Family, Community, and Health Systems Science (F.C.D.S, U.A.S., G.M.K.), College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Robert J Lucero
- School of Nursing (R.J.L.), University of California Los Angeles, Los Angeles, California, USA
| | - François Modave
- Department of MD-Anesthesiology (F.M), College of Medicine, University of Florida, Gainesville, Florida, USA
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Wehrfritz A, Schmidt J, Bremer F, Lang A, Welzer J, Castellanos I. Ethical conflicts associated with COVID-19 pandemic, triage and frailty-unexpected positive disease progression in a 90-year-old patient: A case report. Clin Case Rep 2023; 11:e7710. [PMID: 37476601 PMCID: PMC10354352 DOI: 10.1002/ccr3.7710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023] Open
Abstract
During the COVID 19 pandemic, advanced age, scoring systems, and a shortage of ICU beds were used as cut-offs for ICU admission. This case report describes the epicrisis of an elderly patient who was almost mistakenly not treated in an ICU.
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Affiliation(s)
- Andreas Wehrfritz
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Joachim Schmidt
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Frank Bremer
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Anne‐Katharina Lang
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
| | - Jacob Welzer
- Department of AnaesthesiologyKlinikum FuerthFuerthGermany
| | - Ixchel Castellanos
- Department of AnaesthesiologyUniversity hospital of Erlangen, Faculty of Medicine, Friedrich‐Alexander‐University ErlangenErlangenGermany
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Canzona MR, Love D, Barrett R, Henley J, Bridges S, Koontz A, Nelson S. Piloting an Interprofessional Narrative-Based Interactive Workshop for End-of-Life Conversations: Implications for Learning and Practice. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:862-888. [PMID: 33557720 DOI: 10.1177/0030222821993633] [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]
Abstract
BACKGROUND Based on the principles of Narrative Medicine, this study explored a narrative-based workshop for multi-level interdisciplinary clinicians who have EOL conversations. METHODS Fifty-two clinicians participated in narrative-based interactive workshops. Participants engaged narrative in three forms: viewing narratives, writing/sharing narratives, and co-constructing narratives. Post workshop interviews were conducted and thematically analyzed. RESULTS Five themes characterized how the workshop shaped learning and subsequent care experiences: (1) learning to enter/respond to the patient stories, (2) communicating across professions and disciplines, (3) practicing self-care. Additional themes emphasized (4) barriers to narrative learning and (5) obstacles to applying narrative to practice. DISCUSSION Results highlight the function/utility of narrative forms such as the value of processing emotions via reflective writing, feeling vulnerable while sharing narratives, and appreciating colleagues' obstacles while observing patient-clinician simulations. Challenges associated with narrative such as writing anxiety and barriers to implementation such as time constraints are detailed to inform future initiatives.
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Affiliation(s)
- Mollie Rose Canzona
- Department of Communication, Wake Forest University, Winston-Salem, North Carolina, United States.,Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Deborah Love
- Department of Social Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States.,Novant Health, Winston-Salem, North Carolina, United States
| | - Rolland Barrett
- Forsyth Medical Center, Novant Health, Winston-Salem, North Carolina, United States
| | - Joanne Henley
- Novant Health, Winston-Salem, North Carolina, United States
| | - Sara Bridges
- Novant Health, Winston-Salem, North Carolina, United States
| | - Adam Koontz
- Novant Health, Winston-Salem, North Carolina, United States
| | - Sharon Nelson
- Novant Health, Winston-Salem, North Carolina, United States
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Hadler RA, Clapp JT, Chung JJ, Gutsche JT, Fleisher LA. Escalation and Withdrawal of Treatment for Patients on Extracorporeal Membrane Oxygenation: A Qualitative Study. Ann Surg 2023; 277:e226-e234. [PMID: 33714966 DOI: 10.1097/sla.0000000000004838] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to describe decisions about the escalation and withdrawal of treatment for patients on extracorporeal membrane oxygenation (ECMO). SUMMARY BACKGROUND DATA Interventions premised on facilitating patient autonomy have proven problematic in guiding treatment decisions in intensive care units (ICUs). Calls have thus been made to better understand how decisions are made in critical care. ECMO is an important form of cardiac and respiratory support, but care on ECMO is characterized by prognostic uncertainty, varying time course, and high resource use. It remains unclear how decisions about treatment escalation and withdrawal should be made for patients on ECMO and what role families should play in these decisions. METHODS We performed a focused ethnography in 2 cardiothoracic ICUs in 2 US academic hospitals. We conducted 380 hours of observation, 34 weekly interviews with families of 20 ECMO patients, and 13 interviews with unit clinicians from January to September 2018. Qualitative analysis used an iterative coding process. RESULTS Following ECMO initiation, treatment was escalated as complications mounted until the patient either could be decannulated or interventional options were exhausted. Families were well-informed about treatment and prognosis but played minimal roles in shaping the trajectory of care. CONCLUSIONS Discussion between clinicians and families about prognosis and goals was frequent but did not occasion decision-making moments. This study helps explain why communication interventions intended to maintain patient autonomy through facilitating surrogate participation in decisions have had limited impact. A more comprehensive understanding of upstream factors that predispose courses of critical care is needed.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Jacob T Gutsche
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Sui W, Gong X, Qiao X, Zhang L, Cheng J, Dong J, Zhuang Y. Family members' perceptions of surrogate decision-making in the intensive care unit: A systematic review. Int J Nurs Stud 2023; 137:104391. [PMID: 36442321 DOI: 10.1016/j.ijnurstu.2022.104391] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND A better understanding of the perceptions of family members in making surrogate decisions for loved ones during intensive care is needed to inform the development of targeted supportive interventions. OBJECTIVE To examine and synthesize qualitative data on family members' perceptions of surrogate decision-making in the intensive care unit. DESIGN We conducted a systematic review and qualitative data synthesis. Eligible studies contained family members' quotes about surrogate decision-making experiences and perceptions in adult intensive care units, published in English or Chinese, in a peer-reviewed journal up to February 2022. Data sources included Embase, PubMed, ISI Web of Science, PsychINFO, CINAHL, Biomedical Literature Service System, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Journal. METHODS The searches yielded 5974 identified articles, of which 23 studies were included. At least two different reviewers independently assessed the study quality and extracted data into a Microsoft Excel spreadsheet. A thematic synthesis was performed by classifying all text units into one of the broad themes and subsequently analyzed to inductively develop the first-, second-, and third-order themes. Six family members with experience in intensive care unit surrogate decision-making contributed to the analysis. RESULTS The qualitative data synthesis resulted in five major themes. The following key new insights into family members' perceptions of surrogate decision-making in the intensive care unit were obtained: in individual systems, family members suffered from emotional distress and psychological stress; different cognitive styles emerged; some family members reshaped a new order of life in the disruption; in family systems, the family as a whole was closely connected with each other; and in medical systems families perceived asymmetry in relationships with clinicians, many factors influencing trust, the necessity for role-specific mediators and issues with operations and environments not being sufficiently humanized. CONCLUSION This qualitative synthesis showed that individuals' emotions and cognition underwent complex processes during surrogate decision-making. The family as a whole, with disparate functional states, also faced different processes and outcomes under the crisis situation. At a broader level, the decision-making process reflected society's perceptions of the medical system. Future studies should use these insights to further explore and optimize the many aspects of surrogate decision support measures for families of critically ill patients and include the measurement of outcomes after interventions at multiple layers of the individual, family, and medical systems. REGISTRATION NUMBER The protocol was prospectively published on International Prospective Register of Systematic Reviews (PROSPERO)-CRD42022316687. TWEETABLE ABSTRACT Families of critically ill patients undergo a complex interactional process within the individual, family, and medical systems during surrogate decision-making.
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Affiliation(s)
- Weijing Sui
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China.
| | - Xiaoyan Gong
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China.
| | - Xiaoting Qiao
- School of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Lixin Zhang
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Junning Cheng
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Jing Dong
- School of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yiyu Zhuang
- Nursing Department, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China.
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Lakin JR, Zupanc SN, Lindvall C, Moseley ET, Das S, Sciacca K, Cabral HJ, Burns EA, Carney MT, Itty J, Lopez S, Emmert K, Martin NJ, Lambert S, Polo J, Sanghani S, Dugas JN, Gomez M, Winter MR, Wang N, Gabry-Kalikow S, Dobie A, Amshoff M, Cucinotta T, Joel M, Caruso LB, Ramirez AM, Salerno K, Ogunneye Q, Henault L, Davis AD, Volandes A, Paasche-Orlow MK. Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital. BMJ Open 2022; 12:e065236. [PMID: 35879001 PMCID: PMC9328081 DOI: 10.1136/bmjopen-2022-065236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age. METHODS AND ANALYSIS The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included. ETHICS AND DISSEMINATION The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04857060; ClinicalTrials.gov.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edith A Burns
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Maria T Carney
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jennifer Itty
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Santiago Lopez
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kaitlin Emmert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Narda J Martin
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Sherene Lambert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Jennifer Polo
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Shreya Sanghani
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Julianne N Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michele Gomez
- Commonwealth Care Alliance, Boston, Massachusetts, USA
| | - Michael R Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Alexandra Dobie
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Meredith Amshoff
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Traci Cucinotta
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Milton Joel
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lisa B Caruso
- Boston University School of Medicine, Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Ana Maria Ramirez
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kathleen Salerno
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Qausarat Ogunneye
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions, Waban, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Petrillo LA, Shimer SE, Zhou AZ, Sommer RK, Feldman JE, Hsu KE, Greer JA, Traeger LN, Temel JS. Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study. Cancer 2022; 128:3120-3128. [PMID: 35731234 DOI: 10.1002/cncr.34369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer. METHODS This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication. RESULTS Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making. CONCLUSIONS Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sophia E Shimer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Z Zhou
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert K Sommer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kelly E Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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10
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Chen CH, Wen FH, Chou WC, Chen JS, Chang WC, Hsieh CH, Tang ST. Associations of prognostic-awareness-transition patterns with end-of-life care in cancer patients' last month. Support Care Cancer 2022; 30:5975-5989. [PMID: 35391576 DOI: 10.1007/s00520-022-07007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Cancer patients heterogeneously develop prognostic awareness, and end-of-life cancer care has become increasingly aggressive to the detriment of patients and healthcare sustainability. We aimed to explore the never-before-examined associations of prognostic-awareness-transition patterns with end-of-life care. METHODS Prognostic awareness was categorized into four states: (1) unknown and not wanting to know; (2) unknown but wanting to know; (3) inaccurate awareness; and (4) accurate awareness. We examined associations of our previously identified three prognostic-awareness-transition patterns during 334 cancer patients' last 6 months (maintaining accurate prognostic awareness, gaining accurate prognostic awareness, and maintaining inaccurate/unknown prognostic awareness) and end-of-life care (cardiopulmonary resuscitation, intensive care unit care, mechanical ventilation, chemotherapy/immunotherapy, and hospice care) in cancer patients' last month by multivariate logistic regressions. RESULTS Cancer patients in the maintaining-accurate-prognostic-awareness and gaining-accurate-prognostic-awareness groups had significantly lower odds of cardiopulmonary resuscitation (adjusted odds ratio [95% confidence interval]: 0.22 [0.06-0.78]; and 0.10 [0.01-0.97], respectively) but higher odds of hospice care (3.44 [1.64-7.24]; and 3.28 [1.32-8.13], respectively) in the last month than those in the maintaining inaccurate/unknown prognostic awareness. The maintaining-accurate-prognostic-awareness group had marginally lower odds of chemotherapy or immunotherapy received than the gaining-accurate-prognostic-awareness group (0.58 [0.31-1.10], p = .096]). No differences in intensive care unit care and mechanical ventilation among cancer patients in different prognostic-awareness-transition patterns were observed. CONCLUSION End-of-life care received in cancer patients' last month was associated with the three distinct prognostic-awareness-transition patterns. Cancer patients' accurate prognostic awareness should be facilitated earlier to reduce their risk of receiving aggressive end-of-life care, especially for avoiding chemotherapy/immunotherapy close to death. TRIAL REGISTRATION ClinicalTrials.gov:NCT01912846.
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Affiliation(s)
- Chen Hsiu Chen
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, Republic of China
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, Republic of China.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, Republic of China.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, Republic of China.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Chia-Hsun Hsieh
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China.,Division of Hematology-Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, Republic of China. .,Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China. .,School of Nursing, Medical College, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan, 333, Republic of China.
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11
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Comparison of intuitive assessment and palliative care screening tool in the early identification of patients needing palliative care. Sci Rep 2022; 12:4955. [PMID: 35322098 PMCID: PMC8943025 DOI: 10.1038/s41598-022-08886-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/30/2021] [Indexed: 12/02/2022] Open
Abstract
The intuitive assessment of palliative care (PC) needs and Palliative Care Screening Tool (PCST) are the assessment tools used in the early detection of patients requiring PC. However, the comparison of their prognostic accuracies has not been extensively studied. This cohort study aimed to compare the validity of intuitive assessment and PCST in terms of recognizing patients nearing end-of-life (EOL) and those appropriate for PC. All adult patients admitted to Taipei City Hospital from 2016 through 2019 were included in this prospective study. We used both the intuitive assessment of PC and PCST to predict patients’ 6-month mortality and identified those appropriate for PC. The c-statistic value was calculated to indicate the predictive accuracies of the intuition and PCST. Of 111,483 patients, 4.5% needed PC by the healthcare workers’ intuitive assessment, and 6.7% had a PCST score ≥ 4. After controlling for other covariates, a positive response ‘yes’ to intuitive assessment of PC needs [adjusted odds ratio (AOR) = 9.89; 95% confidence interval (CI) 914–10.71] and a PCST score ≥ 4 (AOR = 6.59; 95%CI 6.17–7.00) were the independent predictors of 6-month mortality. Kappa statistics showed moderate concordance between intuitive assessment and PCST in predicting patients' 6-month mortality (k = 0.49). The c-statistic values of the PCST at recognizing patients’ 6-month mortality was significantly higher than intuition (0.723 vs. 0.679; p < 0.001). As early identification of patients in need of PC could improve the quality of EOL care, our results suggest that it is imperative to screen patients’ palliative needs by using a highly accurate screening tool of PCST.
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Sabouneh R, Lakissian Z, Hilal N, Sharara-Chami R. The State of the Do-Not-Resuscitate Order in a Pediatric Intensive Care Unit in the Middle East: A Retrospective Study. J Palliat Care 2022; 37:99-106. [PMID: 35014894 DOI: 10.1177/08258597211073228] [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
OBJECTIVES The Do-Not-Resuscitate (DNR) order is part of most hospitals' policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. METHODS This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. RESULTS Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested "soft" resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. CONCLUSIONS The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for "soft" resuscitations like administering epinephrine without chest compressions.
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Affiliation(s)
- R Sabouneh
- American University of Beirut Medical Centre (AUBMC)
| | - Z Lakissian
- Dar Al-Wafaa Simulation in Medicine (DAWSIM), AUBMC
| | - N Hilal
- American University of Beirut Medical Centre (AUBMC)
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Abstract
Dementia is a progressive, irreversible illness and leading global cause of death defined by cognitive and subsequent functional decline. Current treatments have limited impact on mortality. In this chapter, we discuss the trajectory of dementia and its variability, markers associated with poorer prognosis (such as poor nutrition, pneumonia, comorbid conditions), the impact of hospitalization on prognosis, and current models of end-of-life palliative care/hospice eligibility (with the use of the Functional Assessment Staging tool and other markers). We then discuss strategies to discuss prognosis with patients and their healthcare proxies using a mental model (Ask, Discover, Anticipate, Provide, Track: ADAPT) and specific skills. Because of progression of dementia variability, prognosis is better discussed in terms of function. For patients with dementia, initiating advance care planning earlier in their disease course allows for more patient involvement (such as to identify a surrogate decision maker).
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Affiliation(s)
- Sinthana U Ramsey
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA, United States
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14
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Harris E, Eng D, Ang Q, Clarke E, Sinha A. Goals of care discussions in acute hospital admissions - Qualitative description of perspectives from patients, family and their doctors. PATIENT EDUCATION AND COUNSELING 2021; 104:2877-2887. [PMID: 34598803 DOI: 10.1016/j.pec.2021.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Goals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor's perspective. METHODS A qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019. RESULTS Many participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear. CONCLUSIONS This study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care. PRACTICE IMPLICATIONS Assessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.
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Affiliation(s)
| | - Derek Eng
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; St John of God Subiaco Hospital, Subiaco, Australia; School of Medicine, University of Notre Dame, Fremantle, Australia.
| | - QiKai Ang
- Royal Perth Hospital, Perth, Australia.
| | | | - Atul Sinha
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; Fiona Stanley Hospital, Murdoch, Australia.
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15
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Basu MR, Partin L, Revette A, Wolfe J, DeCourcey DD. Clinician Identified Barriers and Strategies for Advance Care Planning in Seriously Ill Pediatric Patients. J Pain Symptom Manage 2021; 62:e100-e111. [PMID: 33823242 DOI: 10.1016/j.jpainsymman.2021.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Parents desire more opportunities for advance care planning (ACP), however, large-scale adoption of ACP for seriously ill children remains unrealized. Little is known about current approaches to ACP and strategies to circumvent existing barriers to ACP provision. OBJECTIVE To explore multidisciplinary clinician perceptions about perceived barriers and strategies to improve ACP provision. DESIGN Qualitative study including focus groups conducted with multidisciplinary clinicians at two centers from December 2018-April 2019. Iterative multi-stage thematic analyses were utilized to identify key contexts and themes pertaining to current approaches to ACP, as well as clinician perspectives on ACP barriers and improvement strategies. RESULTS Thirty-five clinicians (physicians, nurses, and psychosocial clinicians) participated in identifying both clinician and perceived patient and family barriers to initiating and engaging in ACP discussions, including mixed messaging, lack of knowledge of patient and family goals, prognostic uncertainty, poor prognostic awareness, unstandardized documentation, and family dynamics. Clinicians also identified strategies to overcome these barriers and to facilitate ACP discussions, including enhancing multidisciplinary communication, creation of a shared ACP communication framework, and formal training in ACP communication to normalize ACP throughout a child's disease trajectory. CONCLUSION Despite ubiquitous recognition of the importance of ACP communication, various clinician- and parent-level barriers were identified which impede ACP in children with serious illness and their families. Improvement strategies should focus on formal clinician training on how to conduct and document longitudinal ACP discussions to ensure care is aligned with family goals and values.
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Affiliation(s)
- Meera R Basu
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts.
| | - Lindsay Partin
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts
| | - Anna Revette
- Survey and Data Management Core, Dana Farber Cancer Institute (A.R.), Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute (J.W.), Boston, Massachusetts
| | - Danielle D DeCourcey
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts
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Lee KP, Wong SYS, Yip BHK, Wong ELY, Lai FTT, Chan D, Chau P, Luk L, Yeoh EK. How common are Chinese patients with multimorbidity involved in decision-making and having a treatment plan? A cross-sectional study. Int J Clin Pract 2021; 75:e14286. [PMID: 33914995 DOI: 10.1111/ijcp.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 11/09/2020] [Accepted: 04/26/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Creating a treatment plan (TP) through shared decision-making (SDM) with healthcare professionals is of paramount importance for patients with multimorbidity (MM). This study aims to estimate the prevalence of SDM and TP in patients with MM and study the association between SDM/TP with patients' confidence to manage their diseases and hospitalization within the previous 1 year. METHOD This cross-sectional study used an internationally recognized survey. A total of 1032 patients aged 60 or above with MM were recruited from a specialist outpatient clinic, general outpatient clinic (GOPC) and a geriatric day hospital. The proportion of patients reported to have SDM and TP was estimated. Associations between the presence of SDM/TP and patients' demographic data, the confidence level to manage their illnesses and hospitalization in previous 1 year were then studied using logistic regression. RESULTS The prevalence of SDM and TP was 35.8% and 82.1%, respectively. The presence of TP was associated with receiving healthcare from the same doctor or in the same facilities and being recruited from GOPC. The presence of SDM (OR = 1.352, P = .089) and TP (OR = 2.384, P < .001) was associated with enhanced confidence in dealing with diseases. CONCLUSION Most people with MM had TP in Hong Kong, but fewer patients had SDM. PRACTICE IMPLICATIONS Ways to promote SDM in HK are needed.
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Affiliation(s)
- Kam Pui Lee
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Samuel Yeung Shan Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Benjamin Hon Kei Yip
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Eliza Lai Yi Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Francisco T T Lai
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Dicken Chan
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Patsy Chau
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Luk
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Eng Kiong Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
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Abstract
Rationale: Medical interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered futile or inappropriate by healthcare providers. In recent years, a multicenter guideline has been released with recommendations on how to resolve conflicts between families and clinicians in these situations and to increase public engagement. Although laypeople are acknowledged as important stakeholders, their perceptions and understanding of the terms "potentially inappropriate" or "futile" treatment have received little formal evaluation.Objectives: To evaluate the community perspective about the meaning of futile treatment.Methods: Six focus groups (two groups each of ages <65, 65-75, and >75 yr) were convened to explore what constitutes futile treatment and who should decide in situations of conflict between doctors and families. Focus group discussions were analyzed using grounded theory.Results: There were 39 participants aged 18 or older with at least one previous hospitalization (personal or by immediate relative). When asked to describe futile or inappropriate treatment, community members found the concept difficult to understand and the terminology inadequate, though when presented with a case describing inappropriate treatment, most participants recognized it as the provision of inappropriate treatment. Several themes emerged regarding participant difficulty with the concept, including inadequate physician-patient communication, lack of public emphasis on end-of-life issues, skepticism that medical treatment can be completely inappropriate, and doubts and fears that medical futility could undermine patient and/or family autonomy. Participants also firmly believed that in situations of conflict families should be the ultimate decision-makers.Conclusions: Public engagement in policy development and discourse around medical futility will first require intense education to familiarize the lay public about use of inappropriate treatment at the end of life.
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Sacco A, Morici N, Villanova L, Viola G, Lissoni B, Forni L, Mazza U, Oliva F. Withdrawal of active treatments in terminally ill heart failure patients. Int J Cardiol 2021; 336:81-83. [PMID: 33964316 DOI: 10.1016/j.ijcard.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart failure (HF) constitutes a growing public health problem in aging societies: when pharmacological therapies fail, HF can be sustained intensively if patients are eligible for either orthotopic heart transplantation (OHT) or mechanical ventricular assistance, otherwise additional treatments could be inappropriate. In December 2017 Italian Legislator brought in the provisions regarding the end-of-life choices, including indications for withdrawing and withholding life-sustaining therapies. The aim of our study was to provide an overview of the daily practice of our center with regard to terminally ill HF patients. METHODS AND RESULTS In April 2019 the 7 intensivist cardiologists and 21 nurses of a tertiary ICCU were asked in, to complete a questionnaire relating to a hypothetical terminally ill HF patient for whom the decision to withdraw active treatment had been made. To assess current practice, we also identified patients who died in the previous 12 months. Out of 29 deceased patients, 18 were identified as terminally ill HF, with no indications for therapy upgrading. We observed a striking disparity between belief and practice. CONCLUSIONS Our survey showed that the care of terminally ill HF patients in our ICCU was characterized by aggressive use of medical therapy and invasive technology. The wide disparity between belief and practice could be in part a consequence of lack of professional training, with regard to law, ethics and communication techniques.
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Affiliation(s)
- A Sacco
- Intensive Cardiac Care Unit and "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - N Morici
- Intensive Cardiac Care Unit and "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Dept. of Clincal Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - L Villanova
- Intensive Cardiac Care Unit and "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - G Viola
- Intensive Cardiac Care Unit and "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - B Lissoni
- Clinical Psicology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - L Forni
- Comitato per l'Etica di Fine Vita, Italy; Università Milano-Bicocca, School of Law, Milano, Italy
| | - U Mazza
- Clinical Psicology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - F Oliva
- Intensive Cardiac Care Unit and "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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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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Kushner B, Holden T, Politi M, Blatnik J, Holden S. A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair. J Surg Res 2020; 259:387-392. [PMID: 33070993 DOI: 10.1016/j.jss.2020.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation. METHODS The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care. RESULTS We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia. CONCLUSIONS SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.
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Affiliation(s)
- Bradley Kushner
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
| | - Timothy Holden
- Division of Geriatrics and Nutritional Science, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mary Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Blatnik
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sara Holden
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Bosch LC, Nathan K, Lu LY, Campbell ST, Gardner MJ, Bishop JA. Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures. J Clin Orthop Trauma 2020; 14:65-68. [PMID: 33717898 PMCID: PMC7920119 DOI: 10.1016/j.jcot.2020.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/27/2020] [Accepted: 09/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis. METHODS A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables. RESULTS The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892). CONCLUSIONS In our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.
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Affiliation(s)
- Liam C. Bosch
- Stanford Medicine, Department of Orthopaedic Surgery, Stanford, CA, 94305, USA,Corresponding author. 300 Pasteur Drive, Edwards Bldg R144, Stanford, CA, 94305, USA.
| | | | - Laura Y. Lu
- Stanford Medical School, Stanford, CA, 94305, USA
| | - Sean T. Campbell
- Stanford Medicine, Department of Orthopaedic Surgery, Stanford, CA, 94305, USA
| | - Michael J. Gardner
- Stanford Medicine, Department of Orthopaedic Surgery, Stanford, CA, 94305, USA
| | - Julius A. Bishop
- Stanford Medicine, Department of Orthopaedic Surgery, Stanford, CA, 94305, USA
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Lawhon VM, England RE, Wallace AS, Williams CP, Williams BR, Niranjan SJ, Ingram SA, Rocque GB. "It's important to me": A qualitative analysis on shared decision-making and patient preferences in older adults with early-stage breast cancer. Psychooncology 2020; 30:167-175. [PMID: 32964517 DOI: 10.1002/pon.5545] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/23/2020] [Accepted: 08/25/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Shared decision-making (SDM) occurs when physicians and patients jointly select treatment that aligns with patient care goals. Incorporating patient preferences into the decision-making process is integral to successful decision-making. This study explores factors influencing treatment selection in older patients with early-stage breast cancer (EBC). METHODS This qualitative study included women age ≥65 years with EBC. To understand role preferences, patients completed the Control Preferences Scale. Semi-structured interviews were conducted to explore patients' treatment selection rationale. Interview transcripts were analyzed using a constant comparative method identifying major themes related to treatment selection. RESULTS Of 33 patients, the majority (48%) desired shared responsibility in treatment decision-making. Interviews revealed that EBC treatment incorporated three domains: Intrinsic and extrinsic influences, clinical characteristics, and patient values. Patients considered 19 treatment selection themes, the most prioritized including physician trust and physical side effects. CONCLUSIONS Because preferences and approach to treatment selection varied widely in this sample of older, EBC patients, more research is needed to determine best practices for preference incorporation to optimize SDM at the time of treatment decisions.
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Affiliation(s)
- Valerie M Lawhon
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rebecca E England
- School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Courtney P Williams
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Beverly R Williams
- Division of Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Soumya J Niranjan
- School of Health Professions, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacey A Ingram
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020; 24:404-408. [PMID: 32863631 PMCID: PMC7435104 DOI: 10.5005/jp-journals-10071-23454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Early initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility. Materials and methods The medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)—within 48 hours of decision of treatment futility and (b) late group (LG)—after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members. Results Out of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups. Conclusion We conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members. How to cite this article Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(6):404–408.
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Affiliation(s)
- Anirban H Choudhuri
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ankit Sharma
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Rajeev Uppal
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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D’Halluin P, Sautenet B, François M, Birmelé B. Les directives anticipées chez des patients en hémodialyse chronique : étude de faisabilité. Nephrol Ther 2020; 16:191-196. [DOI: 10.1016/j.nephro.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/16/2019] [Indexed: 11/30/2022]
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Levy K, Grant PC, Kerr CW, Byrwa DJ, Depner RM. Hospice Patient Care Goals and Medical Students' Perceptions: Evidence of a Generation Gap? Am J Hosp Palliat Care 2020; 38:114-122. [PMID: 32588649 DOI: 10.1177/1049909120934737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The ability to perceive care goals of the dying may be an indicator of future quality patient-centered care. Research conducted on end-of-life goals indicates discrepancies between patients and physicians. OBJECTIVE The aim of this study is to compare end-of-life care goals of hospice patients and medical student perceptions of patient care goals. DESIGN Hospice patients and medical students were surveyed on their care goals and perceptions, respectively, using an 11-item survey of goals previously identified in palliative care literature. Medical student empathy was measured using the Interpersonal Reactivity Index. SETTINGS/PARTICIPANTS Eighty hospice patients and 176 medical students (97 first-year and 79 third-year) in a New York State medical school. RESULTS Medical students ranked 7 of the 11 care goals differently than hospice patients: not being a burden to family (p < .001), time with family and friends (p = .002), being at peace with God (p < .001), dying at home (p = .004), feeling that life was meaningful (p < .001), living as long as possible (p < .001), and resolving conflicts (p < .001). Third-year students were less successful than first-year students in perceiving patient care goals of hospice patients. No significant differences in medical student empathy were found based on student year. CONCLUSIONS Medical students, while empathetic, were generally unsuccessful in perceiving end-of-life care goals of hospice patients in the psychosocial and spiritual domains. Differences impeding the ability of medical students to understand these care goals may be generationally based. Increased age awareness and sensitivity may improve future end-of-life care discussions. Overall, there is a need to recognize the greater dimensionality of the dying in order to provide the most complete patient-centered care.
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Affiliation(s)
- Kathryn Levy
- Hospice & Palliative Care Buffalo, Cheektowaga, NY, USA.,Department of Planning and Research, Trocaire College, Buffalo, NY, USA
| | - Pei C Grant
- Hospice & Palliative Care Buffalo, Cheektowaga, NY, USA
| | | | - David J Byrwa
- Hospice & Palliative Care Buffalo, Cheektowaga, NY, USA.,School of Medicine, 12292University at Buffalo, the State University of New York, Buffalo, NY, USA
| | - Rachel M Depner
- Hospice & Palliative Care Buffalo, Cheektowaga, NY, USA.,Department of Counseling, School and Educational Psychology, 12292University at Buffalo, the State University of New York, Buffalo, NY, USA
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Taylor BES, Narayan V, Jumah F, Al-Mufti F, Nosko M, Roychowdhury S, Nanda A, Gupta G. Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review. Clin Neurol Neurosurg 2020; 194:105798. [PMID: 32222653 DOI: 10.1016/j.clineuro.2020.105798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.
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Affiliation(s)
- Blake E S Taylor
- Department of Neurosurgery, Rutgers- New Jersey Medical School, Newark, NJ, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Nosko
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Radiology, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Neurology, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers- New Jersey Medical School, Newark, NJ, USA; Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Elizabeth Wilcox M, Donnelly JP, Lone NI. Understanding gender disparities in outcomes after sepsis. Intensive Care Med 2020; 46:796-798. [PMID: 32072302 DOI: 10.1007/s00134-020-05961-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/05/2020] [Indexed: 02/01/2023]
Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Critical Care, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
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Ouyang DJ, Lief L, Russell D, Xu J, Berlin DA, Gentzler E, Su A, Cooper ZR, Senglaub SS, Maciejewski PK, Prigerson HG. Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes. PLoS One 2020; 15:e0227971. [PMID: 32069306 PMCID: PMC7028295 DOI: 10.1371/journal.pone.0227971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
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Affiliation(s)
- Daniel J. Ouyang
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Lindsay Lief
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - David Russell
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Sociology, Appalachian State University, Boone, North Carolina, United State of America
| | - Jiehui Xu
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - David A. Berlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - Eliza Gentzler
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Amanda Su
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Zara R. Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Steven S. Senglaub
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Paul K. Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- Department of Radiology, Weill Cornell Medicine, New York, New York, United State of America
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- * E-mail:
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Chen YY, Su M, Huang SC, Chu TS, Lin MT, Chiu YC, Lin KH. Are physicians on the same page about do-not-resuscitate? To examine individual physicians' influence on do-not-resuscitate decision-making: a retrospective and observational study. BMC Med Ethics 2019; 20:92. [PMID: 31801541 PMCID: PMC6894148 DOI: 10.1186/s12910-019-0429-z] [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: 12/03/2018] [Accepted: 11/19/2019] [Indexed: 12/21/2022] Open
Abstract
Background Individual physicians and physician-associated factors may influence patients’/surrogates’ autonomous decision-making, thus influencing the practice of do-not-resuscitate (DNR) orders. The objective of this study was to examine the influence of individual attending physicians on signing a DNR order. Methods This study was conducted in closed model, surgical intensive care units in a university-affiliated teaching hospital located in Northern Taiwan. The medical records of patients, admitted to the surgical intensive care units for the first time between June 1, 2011 and December 31, 2013 were reviewed and data collected. We used Kaplan–Meier survival curves with log-rank test and multivariate Cox proportional hazards models to compare the time from surgical intensive care unit admission to do-not-resuscitate orders written for patients for each individual physician. The outcome variable was the time from surgical ICU admission to signing a DNR order. Results We found that each individual attending physician’s likelihood of signing do-not-resuscitate orders for their patients was significantly different from each other. Some attending physicians were more likely to write do-not-resuscitate orders for their patients, and other attending physicians were less likely to do so. Conclusion Our study reported that individual attending physicians had influence on patients’/surrogates’ do-not-resuscitate decision-making. Future studies may be focused on examining the reasons associated with the difference of each individual physician in the likelihood of signing a do-not-resuscitate order.
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Affiliation(s)
- Yen-Yuan Chen
- Department of Medical Education, Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, National Taiwan University Hospital, #1, Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051, Taiwan
| | - Melany Su
- New York University School of Medicine, #550 1st Avenue, New York, NY, 10016, USA
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, #7 Rd. Chong-Shan S, Taipei, 10002, Taiwan
| | - Tzong-Shinn Chu
- Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, #1 Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, National Taiwan University College of Medicine, #1, Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051, Taiwan
| | - Yu-Chun Chiu
- Department of Medical Education, National Taiwan University Hospital, #7, Rd. Chong-Shan S., Chong-Cheng District, Taipei, 10002, Taiwan.
| | - Kuan-Han Lin
- Department of Healthcare Administration, Asia University, #500, Lioufeng Rd., Wufeng, Taichung, 41354, Taiwan.
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Denis N, Timsit JF, Giaj Levra M, Sakhri L, Duruisseaux M, Schwebel C, Merle P, Pinsolle J, Ferrer L, Moro-Sibilot D, Toffart AC. Impact of systematic advanced care planning in lung cancer patients: A prospective study. Respir Med Res 2019; 77:11-17. [PMID: 31927479 DOI: 10.1016/j.resmer.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/24/2019] [Accepted: 09/29/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND End-of-life (EOL) communication is crucial, particularly for cancer patients. While advanced care planning is still uncommon, we sought to investigate its impact on care intensity in case of organ failure in lung cancer patients. METHODS We prospectively included consecutive lung cancer patients hospitalised at the Grenoble University Hospital, France, between January 1, 2014 and March 31, 2016. Patients could be admitted several times and benefited from advanced care planning based on three care intensities: intensive care, maximal medical care, and exclusive palliative care. Patients' wishes were addressed. RESULTS Data of 739 hospitalisations concerning 482 patients were studied. During the three first admissions, 173 (25%) patients developed organ failure, with intensive care proposed to 56 (32%), maximal medical care to 104 (60%), and exclusive palliative care to 13 (8%). Median time to organ failure was 9 days [IQR 25%-75%: 3-13]. All patients benefited from care intensity that was either equal to or lower than the care proposed. Specific wishes were recorded for 158 (91%) patients, with a discussion about EOL conditions held in 116 (73%). CONCLUSIONS In case of organ failure, advanced care planning helps provide reasonable care intensity. The role of the patient's wishes as to the proposed care must be further investigated. CLINICAL TRIAL REGISTRATION The study was registered at www.ClinicalTrials.gov with the identifier NCT02852629.
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Affiliation(s)
- N Denis
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - J-F Timsit
- Department of medical and infectious resuscitation, hôpital Bichat Claude Bernard, 75018 Paris, France
| | - M Giaj Levra
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Sakhri
- Department of oncology, Institut Daniel Hollard, groupe hospitalier mutualiste, 38000 Grenoble, France
| | - M Duruisseaux
- Department of pneumology, hôpital Louis Pradel, Institut de Cancérologie des Hospices Civils de Lyon, 69500 Bron, France
| | - C Schwebel
- Pôle urgences médecine aiguë, department of intensive care and resuscitation, centre hospitalier universitaire Grenoble Alpes, 38000 Grenoble, France; Laboratoires des pharmaceutiques biocliniques U 1039, université Grenoble Alpes, 38700 La Tronche, France
| | - P Merle
- UMR Inserm 1240, department of pneumology, CHU G Montpied, 63000 Clermont-Ferrand, France
| | - J Pinsolle
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Ferrer
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - D Moro-Sibilot
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France
| | - A-C Toffart
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France.
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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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Zucchelli A, Vetrano DL, Grande G, Calderón-Larrañaga A, Fratiglioni L, Marengoni A, Rizzuto D. Comparing the prognostic value of geriatric health indicators: a population-based study. BMC Med 2019; 17:185. [PMID: 31575376 PMCID: PMC6774220 DOI: 10.1186/s12916-019-1418-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The identification of individuals at increased risk of poor health-related outcomes is a priority. Geriatric research has proposed several indicators shown to be associated with these outcomes, but a head-to-head comparison of their predictive accuracy is still lacking. We therefore aimed to compare the accuracy of five geriatric health indicators in predicting different outcomes among older persons: frailty index (FI), frailty phenotype (FP), walking speed (WS), multimorbidity, and a summary score including clinical diagnoses, functioning, and disability (the Health Assessment Tool; HAT). METHODS Data were retrieved from the Swedish National Study on Aging and Care in Kungsholmen, an ongoing longitudinal study including 3363 people aged 60+. To inspect the accuracy of geriatric health indicators, we employed areas under the receiver operating characteristic curve (AUC) for the prediction of 3-year and 5-year mortality, 1-year and 3-year unplanned hospitalizations (1+), and contacts with healthcare providers in the 6 months before and after baseline evaluation (2+). RESULTS FI, WS, and HAT showed the best accuracy in the prediction of mortality [AUC(95%CI) for 3-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.87), 0.87 (0.85-0.88) and AUC(95%CI) for 5-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.86), 0.86 (0.85-0.88), respectively]. Unplanned hospitalizations were better predicted by the FI [AUC(95%CI) 1-year 0.73 (0.71-0.76); 3-year 0.72 (0.70-0.73)] and HAT [AUC(95%CI) 1-year 0.73 (0.71-0.75); 3-year 0.71 (0.69-0.73)]. The most accurate predictor of multiple contacts with healthcare providers was multimorbidity [AUC(95%CI) 0.67 (0.65-0.68)]. Predictions were generally less accurate among younger individuals (< 78 years old). CONCLUSION Specific geriatric health indicators predict clinical outcomes with different accuracy. Comprehensive indicators (HAT, FI, WS) perform better in predicting mortality and hospitalization. Multimorbidity exhibits the best accuracy in the prediction of multiple contacts with providers.
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Affiliation(s)
- Alberto Zucchelli
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden. .,Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, 25121, Brescia, Italy.
| | - Davide L Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden.,Centro di Medicina dell'Invecchiamento, IRCCS Fondazione Policlinico "A. Gemelli" and Catholic University of Rome, 00168, Rome, Italy
| | - Giulia Grande
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden
| | - Amaia Calderón-Larrañaga
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden.,Stockholm Gerontology Research Center, 11330, Stockholm, Sweden
| | - Alessandra Marengoni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden.,Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, 25121, Brescia, Italy
| | - Debora Rizzuto
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, 11330, Stockholm, Sweden
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Dinnen T, Williams H, Yardley S, Noble S, Edwards A, Hibbert P, Kenkre J, Carson-Stevens A. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Support Palliat Care 2019; 12:bmjspcare-2019-001824. [PMID: 31462421 PMCID: PMC9380496 DOI: 10.1136/bmjspcare-2019-001824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/18/2019] [Accepted: 07/31/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Advance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life. METHODS The National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005-December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement. RESULTS We identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission. CONCLUSION This national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.
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Affiliation(s)
- Toby Dinnen
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Huw Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Sarah Yardley
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Joyce Kenkre
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, Wales
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Becker C, Lecheler L, Hochstrasser S, Metzger KA, Widmer M, Thommen EB, Nienhaus K, Ewald H, Meier CA, Rueter F, Schaefert R, Bassetti S, Hunziker S. Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e195033. [PMID: 31173119 PMCID: PMC6563579 DOI: 10.1001/jamanetworkopen.2019.5033] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear. OBJECTIVE To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR. DATA SOURCES PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018. STUDY SELECTION Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. DATA EXTRACTION AND SYNTHESIS The study was performed according to the PRISMA guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment. RESULTS Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71). CONCLUSIONS AND RELEVANCE Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
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Affiliation(s)
- Christoph Becker
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Leopold Lecheler
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Seraina Hochstrasser
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Kerstin A. Metzger
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Madlaina Widmer
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Emanuel B. Thommen
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Nienhaus
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University Medical Library, University of Basel, Basel, Switzerland
| | - Christoph A. Meier
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Florian Rueter
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Rainer Schaefert
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Toller CAS, Budge MM. Compliance with and Understanding of Advance Directives among Trainee Doctors in the United Kingdom. J Palliat Care 2019. [DOI: 10.1177/082585970602200303] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim To investigate doctors’ response to and understanding of the legal status of advance directives. Methods A vignette-based study administered at palliative medicine, oncology, general practice, and geriatric medicine specialist registrar meetings (United Kingdom). Respondents determined the treatment to provide for a Patient presenting with a myocardial infarction with or without an advance directive requesting maximum therapy. Results Response rate 77% (43/56). Twenty-five percent (10/40) of respondents increased the care that they would provide in response to the advance directive (p=0.004); 77% (33/43) support /strongly support use of advance directives; 51% (22/43) did not know the legal status of advance directives; 44% found that their medical school education was not an important influence on their decision making. Conclusions Advance directives requesting treatment can increase the level of care provided by the physician, however, most trainees chose a level of care different from that in the advance directive. Confusion exists among doctors about the legal status of advance directives, which limits their usefulness. Medical education needs to be improved to train doctors to deal with advance directives.
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Affiliation(s)
| | - Marc M. Budge
- University of Canberra, Canberra, Australian Capital Territory, Australia
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Cherlin E, Schulman-Green D, McCorkle R, Johnson-Hurzeler R, Bradley E. Family Perceptions of Clinicians’ Outstanding Practices in End-of-Life Care. J Palliat Care 2019. [DOI: 10.1177/082585970402000208] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Emily Cherlin
- Yale University, School of Medicine, Department of Epidemiology and Public Health
| | - Dena Schulman-Green
- Yale University, School of Nursing, Center for Excellence in Chronic Illness Care, New Haven
| | - Ruth McCorkle
- Yale University, School of Nursing, Center for Excellence in Chronic Illness Care, New Haven
| | - Rosemary Johnson-Hurzeler
- The Connecticut Hospice and John D. Thompson Institute for Training, Education, and Research, Inc., Branford
| | - Elizabeth Bradley
- Yale University, School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut, U.S.A
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Abstract
While much attention has been directed at improving the quality of care at the end of life, few studies have examined what determines a good death in different individuals. We sought to identify common domains that characterize a good death in a diverse range of community-dwelling individuals, and to describe differences that might exist between minority and non-minority community-dwelling individuals’ views. Using data from 13 focus groups, we identified 10 domains that characterize the quality of the death experience: 1) physical comfort, 2) burdens on family, 3) location and environment, 4) presence of others, 5) concerns regarding prolongation of life, 6) communication, 7) completion and emotional health, 8) spiritual care, 9) cultural concerns, 10) individualization. Differences in minority compared to non-minority views were apparent within the domains of spiritual concerns, cultural concerns, and individualization. The findings may help in efforts to encourage more culturally sensitive and humane end-of-life care for both minority and non-minority individuals.
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38
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Lawson BJ, Burge FI, Mcintyre P, Field S, Maxwell D. Palliative Care Patients in the Emergency Department. J Palliat Care 2019. [DOI: 10.1177/082585970802400404] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Paul Mcintyre
- Department of Palliative Care, Capital District Health Authority, Halifax
| | - Simon Field
- Dalhousie University, Department of Emergency Medicine, Halifax
| | - David Maxwell
- Dalhousie University, Department of Family Medicine, Halifax, Nova Scotia, Canada
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Chen CH, Chen JS, Wen FH, Chang WC, Chou WC, Hsieh CH, Hou MM, Tang ST. An Individualized, Interactive Intervention Promotes Terminally Ill Cancer Patients' Prognostic Awareness and Reduces Cardiopulmonary Resuscitation Received in the Last Month of Life: Secondary Analysis of a Randomized Clinical Trial. J Pain Symptom Manage 2019; 57:705-714.e7. [PMID: 30639758 DOI: 10.1016/j.jpainsymman.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/01/2019] [Accepted: 01/02/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT/OBJECTIVE Half of advanced cancer patients do not have accurate prognostic awareness (PA). However, few randomized clinical trials (RCTs) have focused on facilitating patients' PA to reduce their life-sustaining treatments at end of life (EOL). To address these issues, we conducted a double-blinded RCT on terminally ill cancer patients. METHODS Experimental-arm participants received an individualized, interactive intervention tailored to their readiness for advanced care planning and prognostic information. Control-arm participants received a symptom-management educational treatment. Effectiveness of our intervention in facilitating accurate PA and reducing life-sustaining treatments received, two secondary RCT outcomes, was evaluated by intention-to-treat analysis using multivariate logistic regression. RESULTS Participants (N = 460) were randomly assigned 1:1 to experimental and control arms, each with 215 participants in the final sample. Referring to 151-180 days before death, experimental-arm participants had significantly higher odds of accurate PA than control-arm participants 61-90, 91-120, and 121-150 days before death (adjusted odds ratio [95% CI]: 2.04 [1.16-3.61], 1.94 [1.09-3.45], and 1.93 [1.16-3.21], respectively), but not one to 60 days before death. Experimental-arm participants with accurate PA were significantly less likely than control-arm participants without accurate PA to receive cardiopulmonary resuscitation (CPR) (0.16 [0.03-0.73]), but not less likely to receive intensive care unit care and mechanical ventilation in their last month. CONCLUSION Our intervention facilitated cancer patients' accurate PA early in their dying trajectory, reducing the risk of receiving CPR in the last month. Health care professionals should cultivate cancer patients' accurate PA early in the terminal-illness trajectory to allow them sufficient time to make informed EOL-care decisions to reduce CPR at EOL.
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Affiliation(s)
- Chen Hsiu Chen
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
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40
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Hanson S, Brabrand M, Lassen AT, Ryg J, Nielsen DS. What Matters at the End of Life: A Qualitative Study of Older Peoples Perspectives in Southern Denmark. Gerontol Geriatr Med 2019; 5:2333721419830198. [PMID: 30815513 PMCID: PMC6381425 DOI: 10.1177/2333721419830198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 11/16/2022] Open
Abstract
What matters at the end of life (EOL) among the older population in Denmark is poorly investigated. We used focus groups and in-depth interviews, to identify perspectives within the EOL, along with what influences resuscitation, decision making, and other treatment preferences. We included eligible participants aged ≥65 years in the Region of Southern Denmark. Five focus groups and nine in-depth interviews were conducted, in total 31 participants. We found a general willingness to discuss EOL, and experiences of the process of dying were present among all participants. Three themes emerged during the analysis: (a) Being independent is crucial for the future, (b) Handling and talking about the EOL, and (c) Conditions in Everyday Life are Significant. Life experiences seemed to affect the degree of reflection of EOL and the decision-making process. Knowing your population of interest is crucial, when developing an approach or using an advance care plan from another setting.
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Affiliation(s)
- Stine Hanson
- University of Southern Denmark, Esbjerg, Denmark.,Hospital of South West Jutland, Esbjerg, Denmark
| | - Mikkel Brabrand
- University of Southern Denmark, Esbjerg, Denmark.,Hospital of South West Jutland, Esbjerg, Denmark
| | | | - Jesper Ryg
- University of Southern Denmark, Esbjerg, Denmark.,Odense University Hospital, Denmark
| | - Dorthe S Nielsen
- University of Southern Denmark, Esbjerg, Denmark.,Odense University Hospital, Denmark.,University College Lillebaelt, Denmark
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41
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Kang JH, Bynum JPW, Zhang L, Grodstein F, Stevenson DG. Predictors of Advance Care Planning in Older Women: The Nurses' Health Study. J Am Geriatr Soc 2018; 67:292-301. [PMID: 30537051 DOI: 10.1111/jgs.15656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/13/2018] [Accepted: 09/16/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Relatively little is known regarding predictors of advance care planning (ACP) in former nurses. We aimed to evaluate potential predictors of ACP documentation and discussion. DESIGN Cross-sectional study, 2012-2014. SETTING Nurses' Health Study. PARTICIPANTS A total of 60,917 community-dwelling female nurses aged 66 to 93 years living across the United States. MEASUREMENTS Based on self-reports, participants were categorized as having (1) only ACP documentation, (2) ACP documentation and a recent ACP discussion with a healthcare provider, or (3) neither. Multivariable log-binomial models were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of the two separate ACP categories vs those with neither. We evaluated various demographic, health, and social factors. RESULTS The large majority (84%) reported ACP documentation; 35% reported a recent ACP discussion. Demographic factors such as age and race were associated with both ACP categories. In multivariable analyses, race was most strongly associated: compared with whites, African Americans were 27% less likely (PR = 0.73; 95% CI = 0.69-0.78) to report ACP documentation alone and 41% (PR = 0.59; 95% CI = 0.54-0.66) less likely to report documentation with discussion. Additionally, health/healthcare-related characteristics were more strongly associated with ACP documentation plus discussion. Women with functional limitations (PR = 1.15; 95% CI = 1.10-1.20), women who were recently hospitalized (PR: 1.10; 95% CI = 1.08-1.12) or women who had seen a physician for health symptoms (PR = 1.43; 95% CI = 1.35-1.52) or screening (PR = 1.40; 95% CI = 1.32-1.49) were more likely to report having both ACP documentation and discussion. Social factors showed limited relationships with ACP documentation only; for documentation plus discussion, being widowed and living alone was associated with higher prevalence (PR = 1.21; 95% CI = 1.19-1.24) and having little emotional support was associated with lower prevalence (PR = 0.84; 95% CI = 0.81-0.86). CONCLUSIONS Among older nurses, most of whom reported having documented ACP, 35% reported recent patient-clinician ACP discussions, indicating a major participatory gap in an element critical to ACP effectiveness. Even in nurses, African Americans reported less ACP documentation or discussion. J Am Geriatr Soc 67:292-301, 2019.
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Affiliation(s)
- Jae H Kang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Julie P W Bynum
- Division of Geriatrics and Palliative Care, University of Michigan School of Medicine, Ann Arbor, Michigan.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Lu Zhang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,IBM-Watson Health, Cambridge, Massachusetts
| | - Francine Grodstein
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - David G Stevenson
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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42
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Fan SY, Wang YW, Lin IM. Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision. BMC Palliat Care 2018; 17:114. [PMID: 30305068 PMCID: PMC6180419 DOI: 10.1186/s12904-018-0367-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As the "do not resuscitate" (DNR) discussion involves communication, this study explored (1) the effects of a title that included "allow natural death", and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion. METHODS Healthy adults (n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used. RESULTS There was a significantly higher probability of signing the DNR order when the title included "allow natural death" (t = - 4.51, p < 0.001), when comprehensive information was provided (F = 60.64, p < 0.001), and when there were worse outcomes (F = 292.16, p < 0.001). Common information needs included remaining life period and the prognosis. Common barriers were the families' worries and uncertainty about future physical changes. CONCLUSION The title, information contents, and outcomes may influence the DNR decisions. Health-care providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.
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Affiliation(s)
- Sheng-Yu Fan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Wei Wang
- Department of Family Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - I-Mei Lin
- Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
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Ekaireb R, Ahalt C, Sudore R, Metzger L, Williams B. "We Take Care of Patients, but We Don't Advocate for Them": Advance Care Planning in Prison or Jail. J Am Geriatr Soc 2018; 66:2382-2388. [PMID: 30300941 DOI: 10.1111/jgs.15624] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/03/2018] [Accepted: 08/23/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate correctional healthcare providers' knowledge of and experience with advance care planning (ACP), their perspectives on barriers to ACP in correctional settings, and how to overcome those barriers. DESIGN Qualitative. SETTING Four prisons in 2 states and 1 large city jail in a third state. PARTICIPANTS Correctional healthcare providers (e.g., physicians, nurses, social workers; N=24). RESULTS Participants demonstrated low baseline ACP knowledge; 85% reported familiarity with ACP, but only 42% provided accurate definitions. Fundamental misconceptions included the belief that providers provided ACP without soliciting inmate input. Multiple ACP barriers were identified, many of which are unique to prison and jail facilities, including provider uncertainty about the legal validity of ACP documents in prison or jail, inmate mistrust of the correctional healthcare system, inmates' isolation from family and friends, and institutional policies that restrict use of ACP. Clinicians' suggestions for overcoming those barriers included ACP training for clinicians, creating psychosocial support opportunities for inmates, revising policies that limit ACP, and systematically integrating ACP into healthcare practice. CONCLUSION Despite an increasing number of older and seriously ill individuals in prisons and jails, many correctional healthcare providers lack knowledge about ACP. In addition to ACP barriers found in the community, there are unique barriers to ACP in prisons and jails. Future research and policy innovation are needed to develop clinical training programs and identify ACP implementation strategies for use in correctional settings. J Am Geriatr Soc 66:2382-2388, 2018.
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Affiliation(s)
- Rachel Ekaireb
- Division of Geriatrics, University of California San Francisco, San Francisco, California
| | - Cyrus Ahalt
- Division of Geriatrics, University of California San Francisco, San Francisco, California
| | - Rebecca Sudore
- Division of Geriatrics, University of California San Francisco, San Francisco, California
| | - Lia Metzger
- New York Medical College, Valhalla, New York
| | - Brie Williams
- Division of Geriatrics, University of California San Francisco, San Francisco, California
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44
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Watson R, Bryant J, Sanson-Fisher R, Mansfield E, Evans TJ. What is a 'timely' diagnosis? Exploring the preferences of Australian health service consumers regarding when a diagnosis of dementia should be disclosed. BMC Health Serv Res 2018; 18:612. [PMID: 30081889 PMCID: PMC6080387 DOI: 10.1186/s12913-018-3409-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 07/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently the dementia field has shifted focus away from the early diagnosis debate in favour of 'timely' diagnosis. 'Timely' diagnosis disclosure takes into consideration the preferences and unique circumstances of the individual. Determining when diagnosis disclosure is 'timely' may be particularly complex if there are differing views between the individual, their family, and their health care providers regarding disclosure. This study explores the preferences of consumers regarding when a diagnosis of dementia should be communicated. METHODS A cross-sectional survey was conducted with English-speaking adults attending outpatient clinics at an Australian hospital. Participants were recruited by a research assistant in the clinic waiting room and invited to complete the survey on a web-connected iPad. The survey included questions examining socio-demographics and experience with dementia. Two scenarios were used to explore preferences for timing of diagnosis disclosure. RESULTS Of 446 participants, 92% preferred a diagnosis of dementia to be disclosed as soon as possible. Preferences were not associated with socio-demographics or previous dementia experience. Most participants also preferred disclosure to occur as soon as possible if their spouse or partner was diagnosed with dementia (88%). There was strong correlation between preferences for self and preferences for spouse (0.91). CONCLUSIONS These findings provide guidance to health care providers about preferences for disclosure of a dementia diagnosis, and may help to overcome potential barriers to timely diagnosis. As the prevalence of dementia increases, consumers' preference for diagnosis to occur as soon as possible has important implications for the health system.
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Affiliation(s)
- Rochelle Watson
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, W4 HMRI Building, Callaghan, NSW, 2308, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, Lot 1 Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia.
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, W4 HMRI Building, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Lot 1 Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, W4 HMRI Building, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Lot 1 Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia
| | - Elise Mansfield
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, W4 HMRI Building, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Lot 1 Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia
| | - Tiffany-Jane Evans
- Hunter Medical Research Institute, Lot 1 Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia
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Ethier JL, Paramsothy T, You JJ, Fowler R, Gandhi S. Perceived Barriers to Goals of Care Discussions With Patients With Advanced Cancer and Their Families in the Ambulatory Setting: A Multicenter Survey of Oncologists. J Palliat Care 2018; 33:125-142. [PMID: 29607704 DOI: 10.1177/0825859718762287] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting. METHODS A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important). RESULTS Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients' inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient's refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions. CONCLUSION Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.
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Affiliation(s)
- Josee-Lyne Ethier
- 1 Department of Medical Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Thivaher Paramsothy
- 2 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - John J You
- 3 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,4 Department Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robert Fowler
- 5 Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,6 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sonal Gandhi
- 2 Division of Medical Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Sudore RL, Heyland DK, Lum HD, Rietjens JAC, Korfage IJ, Ritchie CS, Hanson LC, Meier DE, Pantilat SZ, Lorenz K, Howard M, Green MJ, Simon JE, Feuz MA, You JJ. Outcomes That Define Successful Advance Care Planning: A Delphi Panel Consensus. J Pain Symptom Manage 2018; 55:245-255.e8. [PMID: 28865870 PMCID: PMC5794507 DOI: 10.1016/j.jpainsymman.2017.08.025] [Citation(s) in RCA: 224] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/18/2017] [Accepted: 08/20/2017] [Indexed: 11/29/2022]
Abstract
CONTEXT Standardized outcomes that define successful advance care planning (ACP) are lacking. OBJECTIVE The objective of this study was to create an Organizing Framework of ACP outcome constructs and rate the importance of these outcomes. METHODS This study convened a Delphi panel consisting of 52 multidisciplinary, international ACP experts including clinicians, researchers, and policy leaders from four countries. We conducted literature reviews and solicited attendee input from five international ACP conferences to identify initial ACP outcome constructs. In five Delphi rounds, we asked panelists to rate patient-centered outcomes on a seven-point "not-at-all" to "extremely important" scale. We calculated means and analyzed panelists' input to finalize an Organizing Framework and outcome rankings. RESULTS Organizing Framework outcome domains included process (e.g., attitudes), actions (e.g., discussions), quality of care (e.g., satisfaction), and health care (e.g., utilization). The top five outcomes included 1) care consistent with goals, mean 6.71 (±SD 0.04); 2) surrogate designation, 6.55 (0.45); 3) surrogate documentation, 6.50 (0.11); 4) discussions with surrogates, 6.40 (0.19); and 5) documents and recorded wishes are accessible when needed 6.27 (0.11). Advance directive documentation was ranked 10th, 6.01 (0.21). Panelists raised caution about whether "care consistent with goals" can be reliably measured. CONCLUSION A large, multidisciplinary Delphi panel developed an Organizing Framework and rated the importance of ACP outcome constructs. Top rated outcomes should be used to evaluate the success of ACP initiatives. More research is needed to create reliable and valid measurement tools for the highest rated outcomes, particularly "care consistent with goals."
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; Veteran Affairs Medical Center, San Francisco, California, USA.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Clinical Evaluation Research Unit, Kingston General Hospital, Ontario, Canada
| | - Hillary D Lum
- Veteran Affairs Eastern Colorado Geriatrics Research Education and Clinical Center (GRECC), Denver, Colorado, USA; Department of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Karl Lorenz
- Veteran Affairs Medical Center, Palo Alto, California, USA; Stanford University, Palo Alto, California, USA
| | - Michelle Howard
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Green
- Departments of Humanities and Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jessica E Simon
- Departments of Oncology, Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mariko A Feuz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; Veteran Affairs Medical Center, San Francisco, California, USA
| | - John J You
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Suarez-de-la-Rica A, Castro-Arias C, Latorre J, Gilsanz F, Maseda E. Prognosis and predictors of mortality in critically ill elderly patients. ACTA ACUST UNITED AC 2017; 65:143-148. [PMID: 29242031 DOI: 10.1016/j.redar.2017.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/03/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES to evaluate mortality of patients≥80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it. MATERIAL AND METHODS observational retrospective study of patients≥80 years admitted to SICU between June 2012 and June 2015. RESULTS a total of 299 patients were included, 54 of them died in the SICU (18.1%) and 80 patients (26.8%) died during their hospital stay. SICU mortality was independently related to age (OR=1.125; 95%CI: 1.042-1.215; P=.003), SAPS II (OR=1.026; 95% CI: 1.008-1.044; P=.004), need for renal replacement therapy (RRT) (OR=1.960; 95%CI: 1.046-3.671; P=.036) and need for mechanical ventilation for more than 24hours (OR=2.834; 95%CI: 1.244-6.456; P=.013). Factors independently related to hospital mortality were age (OR=1.125; 95%CI: 1.054-1.192; P<.001), SOFA score (OR=1.154; 95% CI: 1.079-1.235; P<.001), need for RRT (OR=1.924; 95%CI: 1.121-3.302; p=0.018) and need for mechanical ventilation for more than 24hours (OR=3.144; 95% CI: 1.771-5.584; P<.001). CONCLUSIONS In critically ill patients over 80 years hospital mortality was independently related to age, SOFA score, RRT need and need for mechanical ventilation for more than 24hours. Our results raise important issues about end-of-life care and life-sustaining interventions in elderly, critically ill patients.
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Affiliation(s)
- A Suarez-de-la-Rica
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España.
| | - C Castro-Arias
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - J Latorre
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - F Gilsanz
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - E Maseda
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
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Bentur N, Sternberg S. Implementation of Advance Care Planning in Israel: A Convergence of Top-Down and Bottom-Up Processes. THE GERONTOLOGIST 2017; 59:420-425. [DOI: 10.1093/geront/gnx157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Netta Bentur
- Myers-JDC-Brookdale Institute, Jerusalem, Israel
| | - Shelley Sternberg
- Acute Care Geriatrics, Geriatric Division, the Ministry of Health, Jerusalem, Israel
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50
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Lamahewa K, Mathew R, Iliffe S, Wilcock J, Manthorpe J, Sampson EL, Davies N. A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia. Health Expect 2017. [PMID: 28640487 PMCID: PMC5750695 DOI: 10.1111/hex.12593] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. Objective To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. Design Qualitative methodology using focus groups and semi‐structured interviews and thematic analysis methods. Settings and participants Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. Results Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. Conclusions This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on‐going approach to conversation may increase preparedness and family carers’ expectations of end of life.
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Affiliation(s)
- Kethakie Lamahewa
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rammya Mathew
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
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