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Hanson S, Lassen A, Nielsen D, Ryg J, Forero R, Brabrand M. Resuscitation Preferences of Older Acutely Admitted Medical and Mentally Competent Patients with One and Six Months Follow-up. Resuscitation 2023:109836. [PMID: 37196801 DOI: 10.1016/j.resuscitation.2023.109836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
AIM Determining patients' cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge. METHODS This survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later "In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?" Possible responses were confined to "definitely yes", "definitely no", "uncertain", and "prefer not to answer". RESULTS In total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71-82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively. CONCLUSION and Relevance In this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.
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Affiliation(s)
- Stine Hanson
- Department of Regional Health Research, Center-Esbjerg, University of Southern Denmark.
| | - Annmarie Lassen
- Department of Emergency Medicine, Odense University Hospital, Denmark, Institute of Clinical Research, University of Southern Denmark
| | - Dorthe Nielsen
- Family focused healthcare research Centre, Odense University Hospital; Geriatric Research Unit, Department of Geriatric Medicine, Odense University Hospital, Denmark, Department of Clinical Research, University of Southern Denmark
| | - Jesper Ryg
- Geriatric Research Unit, Department of Geriatric Medicine, Odense University Hospital, Denmark, Department of Clinical Research, University of Southern Denmark
| | - Roberto Forero
- Simpson Centre for Health Services Research, School of Clinical Medicine, UNSW Medicine & Health, SWS Clinical Campuses, Liverpool Hospital, UNSW, Sydney and Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool BC, 1871, NSW, Australia
| | - Mikkel Brabrand
- Department of Emergency, Medicine, Hospital of South West Jutland, Denmark, University of Southern Denmark, Institute of Regional Health Research, Center-Esbjerg, University of Southern Denmark
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2
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Battisti KA, Cohen DM, Bourgeois T, Kline D, Zhao S, Iyer MS. A Paucity of Code Status Documentation Despite Increasing Complex Chronic Disease in Pediatrics. J Palliat Med 2020; 23:1452-1459. [DOI: 10.1089/jpm.2019.0630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Katherine A. Battisti
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine/Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Daniel M. Cohen
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine/Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Tran Bourgeois
- Department of Research and Development, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David Kline
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Songzhu Zhao
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Maya S. Iyer
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine/Nationwide Children's Hospital, Columbus, Ohio, USA
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3
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A cross-sectional investigation of communication in Do-Not-Resuscitate orders in Dutch hospitals. Resuscitation 2020; 154:52-60. [DOI: 10.1016/j.resuscitation.2020.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/21/2022]
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4
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Instability in End-of-Life Care Preference Among Heart Failure Patients: Secondary Analysis of a Randomized Controlled Trial in Singapore. J Gen Intern Med 2020; 35:2010-2016. [PMID: 32103441 PMCID: PMC7351942 DOI: 10.1007/s11606-020-05740-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Efforts to improve quality of end-of-life (EOL) care are increasingly focused on eliciting patients' EOL preference through advance care planning (ACP). However, if patients' EOL preference changes over time and their ACP documents are not updated, these documents may no longer be valid at the time EOL decisions are made. OBJECTIVES To assess extent and correlates of changes in stated preference for aggressive EOL care over time. DESIGN Secondary analysis of data from a randomized controlled trial of a formal ACP program versus usual care in Singapore. PATIENTS Two hundred eighty-two patients with heart failure (HF) and New York Heart Association Classification III and IV symptoms were recruited and interviewed every 4 months for up to 2 years to assess their preference for EOL care. Analytic sample included 200 patients interviewed at least twice. RESULTS Nearly two thirds (64%) of patients changed their preferred type of EOL care at least once. Proportion of patients changing their stated preference for type of EOL care increased with time and the change was not unidirectional. Patients who understood their prognosis correctly were less likely to change their preference from non-aggressive to aggressive EOL care (OR 0.66, p value 0.07) or to prefer aggressive EOL care (OR 0.53; p value 0.001). On the other hand, patient-surrogate discussion of care preference was associated with a higher likelihood of change in patient preference from aggressive to non-aggressive EOL care (OR 1.83; p value 0.03). CONCLUSION The study provides evidence of instability in HF patients' stated EOL care preference. This undermines the value of an ACP document recorded months before EOL decisions are made unless a strategy exists for easily updating this preference. TRIAL REGISTRATION ClinicalTrials.gov: NCT02299180.
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5
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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6
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Predicting the probability of survival with mild or moderate neurological dysfunction after in-hospital cardiopulmonary arrest: The GO-FAR 2 score. Resuscitation 2019; 146:162-169. [PMID: 31821836 DOI: 10.1016/j.resuscitation.2019.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Good Outcome Following Attempted Resuscitation (GO-FAR) Score uses pre-arrest factors to predict survival after In-Hospital Cardiac Arrest (IHCA) with minimal neurological dysfunction, (cerebral performance category (CPC) ≤1). Moderate neurological dysfunction (CPC ≤2) may be a more acceptable outcome. OBJECTIVE To predict survival after IHCA with mild or moderate neurological dysfunction based on pre-arrest factors. METHODS 52,468 patients with IHCA from 2012-2017. Data was divided into training (44%), testing (22%), and validation (34%) sets. Univariate analysis was used to identify variables with >3% difference in survival with CPC ≤2. These variables carried forward to the multivariate logistic regression model. The most parsimonious model that best classified patients as having a very poor (≤5%), below average (≤10%), average (11%-30%), or above average (>30%) likelihood of survival with CPC ≤2 was chosen. RESULTS Age >85, admission CPC <2, and non-surgical admission were strongly association with poor survival (-12.1%, -14.4%, and -18%, respectively). Nine variables were included in the logistic regression analysis. The final updated model, GO FAR 2, categorized 6.2% of patients with a very poor predicted survival, 24.8% of patients with a below average predicted survival, and 11.3% with above average predicted survival. The observed survival among those with very poor predicted survival was 4.5%. CONCLUSION The GO FAR 2 score provides clinicians with a prognostic estimate of the likelihood of a good outcome after IHCA based on pre-arrest patient factors. Future research is required to validate the GO-FAR 2 score.
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7
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Kerkham T, Brain M. Goals of care conversations and documentation in patients triggering medical emergency team calls. Intern Med J 2019; 50:1373-1376. [PMID: 31661181 DOI: 10.1111/imj.14667] [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: 09/16/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is widely accepted that early discussions about goals of care (GOC) should occur during a hospital admission. Whilst rapid response systems such as Medical Emergency Team (MET) calls were designed to identify patients at risk of deterioration early enough in their illness to intervene, it is becoming apparent that these teams frequently diagnose the dying patient. AIMS To determine how frequently Launceston General Hospital MET doctors are involved in discussions surrounding GOC. METHODS A retrospective audit of all MET calls and Code Blues at the Launceston General Hospital over an 18 month period was performed. RESULTS 50% of MET calls occurred in patients with no valid GOC form completed prior. At 3% of events, the GOC form was completed for the first time, and at 3% it was modified. At a further 3% the notes implied there had been a modification to the GOC but the form had not been completed. CONCLUSIONS This audit confirms that documentation surrounding GOC is inadequate, and that at 9% of MET calls, MET doctors are involved in discussions surrounding treatment limitations. This suggests that further education and training is required for doctors working in inpatient care, including those who staff the MET.
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Affiliation(s)
- Telena Kerkham
- Department of General and Acute Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Matthew Brain
- Intensive Care Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
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8
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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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9
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Nimmon L, Bates J, Kimel G, Lingard L. Patients with heart failure and their partners with chronic illness: interdependence in multiple dimensions of time. J Multidiscip Healthc 2018; 11:175-186. [PMID: 29588596 PMCID: PMC5858542 DOI: 10.2147/jmdh.s146938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Informal caregivers play a vital role in supporting patients with heart failure (HF). However, when both the HF patient and their long-term partner suffer from chronic illness, they may equally suffer from diminished quality of life and poor health outcomes. With the focus on this specific couple group as a dimension of the HF health care team, we explored this neglected component of supportive care. Materials and methods From a large-scale Canadian multisite study, we analyzed the interview data of 13 HF patient-partner couples (26 participants). The sample consisted of patients with advanced HF and their long-term, live-in partners who also suffer from chronic illness. Results The analysis highlighted the profound enmeshment of the couples. The couples' interdependence was exemplified in the ways they synchronized their experience in shared dimensions of time and adapted their day-to-day routines to accommodate each other's changing health status. Particularly significant was when both individuals were too ill to perform caregiving tasks, which resulted in the couples being in a highly fragile state. Conclusion We conclude that the salience of this couple group's oscillating health needs and their severe vulnerabilities need to be appreciated when designing and delivering HF team-based care.
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Affiliation(s)
- Laura Nimmon
- Centre for Health Education Scholarship.,Department of Occupational Science and Occupational Therapy
| | - Joanna Bates
- Centre for Health Education Scholarship.,Department of Family Practice, Faculty of Medicine, University of British Columbia
| | - Gil Kimel
- Palliative Care Program, St Paul's Hospital.,Department of Medicine, Division of Internal Medicine, University of British Columbia, Vancouver, BC
| | - Lorelei Lingard
- Centre for Education Research and Innovation, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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10
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Tang ST, Wen FH, Chang WC, Hsieh CH, Chou WC, Chen JS, Hou MM. Preferences for Life-Sustaining Treatments Examined by Hidden Markov Modeling Are Mostly Stable in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2017; 54:628-636.e2. [PMID: 28782702 DOI: 10.1016/j.jpainsymman.2017.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Stability of life-sustaining treatment (LST) preferences at end of life (EOL) has not been well established for terminally ill cancer patients nor have transition probabilities been explored between different types of preferences. OBJECTIVE We assessed the stability of cancer patients' LST preferences at EOL by identifying distinct LST preference states and examining the probability of each state transitioning to other states between consecutive time points. METHODS Stability of LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, cardiac massage, intubation with mechanical ventilation, intravenous nutrition support, and nasogastric tube feeding) was examined among 303 cancer patients in their last six months by hidden Markov modeling. RESULTS Six distinct LST preference states (initial size) were identified: uniformly preferring (8.3%), uniformly rejecting (33.8%), and uniformly uncertain about (20.5%) LST, favoring intravenous nutrition support but rejecting other treatments (19.9%), and favoring (3.6%) or uncertain about (14.0%) nutrition support and ICU care while rejecting other treatments. Shifts between LST preference states were relatively small between any two time points (transition probability of staying at the same state was 92.1% to 97.5%), except for the state characterized by uncertainty about nutrition support and ICU care while rejecting other treatments, in which 8.3% of patients shifted LST preferences toward uniform uncertainty at a subsequent assessment. CONCLUSIONS Our patients' LST preferences remained stable without prominent shifts toward preferring less aggressive LSTs even when death approached. Clarifying patients' understanding and expectations about LST efficacy and tailoring interventions to the unique needs of patients in each state may provide personalized EOL care.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
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11
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Psotka MA, McKee KY, Liu AY, Elia G, De Marco T. Palliative Care in Heart Failure: What Triggers Specialist Consultation? Prog Cardiovasc Dis 2017; 60:215-225. [PMID: 28483606 DOI: 10.1016/j.pcad.2017.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) continues to cause substantial death and suffering despite the availability of numerous medical, surgical, and technological therapeutic advancements. As a patient-centered holistic discipline focused on improving quality of life and decreasing anguish, palliative care (PC) has a crucial role in the care of HF patients that has been acknowledged by multiple international guidelines. PC can be provided by all members of the HF care team, including but not limited to practitioners with specialty PC training. Unfortunately, despite recommendations to routinely include PC techniques and providers in the care of HF patients, use of general PC strategies as well as expert PC consultation is limited by a dearth of evidence-based interventions in the HF population and knowledge as to when to initiate these interventions, uncertainty regarding patient desires, prognosis, and the respective roles of each member of the care team, and a general shortage of specialist PC providers. This review seeks to provide guidance as to when to employ the limited resource of specialist PC practitioners, in combination with services from other members of the care team, to best tend to HF patients as their disease progresses and eventually overcomes.
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Affiliation(s)
- Mitchell A Psotka
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Kanako Y McKee
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Albert Y Liu
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Giovanni Elia
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, San Francisco, CA.
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12
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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13
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Abstract
Heart failure is the major cause of morbidity and mortality in the United States. Stage D heart failure has a greater mortality rate than many cancers and has equivalent symptom burden and severity. There has been a paradigm shift in our understanding of the pathophysiology of heart failure. Progressive heart failure is associated with ventricular remodeling and a maladaptive neurohumoral response. Drug classes have evolved that curtail ventricular remodeling, and blunt neurohumoral responses reduce morbidity and mortality. Despite combination drug and device therapies, the management of Stage D heart failure includes palliation. Both cardiology and palliative specialists need to learn from one another in order to palliate these highly symptomatic patients. Such collaboration will enhance care and are the basis for well-conceived research trials.
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Affiliation(s)
- Mellar P Davis
- The Harry R Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
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14
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Laakkonen ML, Pitkala KH, Strandberg TE. Terminally Ill Elderly Patient's Experiences, Attitudes, and Needs: A Qualitative Study. OMEGA-JOURNAL OF DEATH AND DYING 2016. [DOI: 10.2190/kvm3-ulm7-0ruh-kvqh] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this qualitative study was to clarify how terminally ill elderly patients in acute wards perceive the end of life and what are their needs and wishes regarding care. The patients, despite their advanced illness, wished to be treated actively and hoped for more conversations with doctors about active care. They were content with their daily care but evaluated the care in light of the great workload of the nurses, forgiving them for not having time to talk to individual patients. They had specific modest wishes, but were reluctant to express even these because of concern about troubling their caregivers. We conclude that death remained a distant abstraction for these patients with a terminal prognosis. The challenge is to create an intimate caring atmosphere, where the issues related to dying may be elaborated in interaction and the last wishes expressed in a safe atmosphere.
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15
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Tang ST, Wen FH, Hsieh CH, Chou WC, Chang WC, Chen JS, Chiang MC. Preferences for Life-Sustaining Treatments and Associations With Accurate Prognostic Awareness and Depressive Symptoms in Terminally Ill Cancer Patients' Last Year of Life. J Pain Symptom Manage 2016; 51:41-51.e1. [PMID: 26386187 DOI: 10.1016/j.jpainsymman.2015.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT The stability of life-sustaining treatment (LST) preferences at end of life (EOL) has been established. However, few studies have assessed preferences more than two times. Furthermore, associations of LST preferences with modifiable variables of accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms have been investigated in cross-sectional studies only. OBJECTIVES To explore longitudinal changes in LST preferences and their associations with accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms in terminally ill cancer patients' last year. METHODS LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, intubation, and mechanical ventilation) were measured approximately every two weeks. Changes in LST preferences and their associations with independent variables were examined by hierarchical generalized linear modeling with logistic regression. RESULTS Participants (n = 249) predominantly rejected cardiopulmonary resuscitation, ICU care, intubation, and mechanical ventilation at EOL without significant changes as death approached. Patients with inaccurate prognostic awareness were significantly more likely than those with accurate understanding to prefer ICU care, intubation, and mechanical ventilation than to reject these LSTs. Patients with more severe depressive symptoms were less likely to prefer ICU care and to be undecided about wanting ICU care and mechanical ventilation than to reject such LSTs. LST preferences were not associated with physician-patient EOL care discussions, which were rare in our sample. CONCLUSION LST preferences are stable in cancer patients' last year. Facilitating accurate prognostic awareness and providing adequate psychological support may counteract the increasing trend for aggressive EOL care and minimize emotional distress during EOL care decisions.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Taoyuan, Taiwan.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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El-Jawahri A, Mitchell SL, Paasche-Orlow MK, Temel JS, Jackson VA, Rutledge RR, Parikh M, Davis AD, Gillick MR, Barry MJ, Lopez L, Walker-Corkery ES, Chang Y, Finn K, Coley C, Volandes AE. A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients. J Gen Intern Med 2015; 30:1071-80. [PMID: 25691237 PMCID: PMC4510229 DOI: 10.1007/s11606-015-3200-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/17/2014] [Accepted: 01/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. INTERVENTION Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). MAIN MEASURES The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). CONCLUSIONS Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. TRIAL REGISTRATION Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.
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Affiliation(s)
- Areej El-Jawahri
- Hematology-Oncology Department, Massachusetts General Hospital, 55 Fruit Street, Cox 120, Boston, MA, 02114, USA,
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Auriemma CL, Nguyen CA, Bronheim R, Kent S, Nadiger S, Pardo D, Halpern SD. Stability of end-of-life preferences: a systematic review of the evidence. JAMA Intern Med 2014; 174:1085-92. [PMID: 24861560 PMCID: PMC8243894 DOI: 10.1001/jamainternmed.2014.1183] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Policies and practices that promote advance care planning and advance directive completion implicitly assume that patients' choices for end-of-life (EOL) care are stable over time, even with changes in health status. OBJECTIVE To systematically evaluate the evidence on the stability of EOL preferences over time and with changes in health status. EVIDENCE REVIEW We searched for longitudinal studies of patients' preferences for EOL care in PubMed, EMBASE, and using citation review. Studies restricted to preferences regarding the place of care at the EOL were excluded. FINDINGS A total of 296 articles were assessed for eligibility, and 59 met inclusion criteria. Twenty-four articles had sufficient data to extract or calculate the percentage of individuals with stable preferences or the percentage of total preferences that were stable over time. In 17 studies (71%) more than 70% of patients' preferences for EOL care were stable over time. Preference stability was generally greater among inpatients and seriously ill outpatients than among older adults without serious illnesses (P < .002). Patients with higher education and who had engaged in advance care planning had greater preference stability, and preferences to forgo therapies were generally more stable than preferences to receive therapies. Among 9 of the 24 studies (38%) assessing changes in health status, no consistent relationship with preference changes was identified. CONCLUSIONS AND RELEVANCE Considerable variability among studies in the methods of preference assessment, the time between assessments, and the definitions of stability preclude meta-analytic estimates of the stability of patients' preferences and the factors influencing these preferences. Although more seriously ill patients and those who engage in advance care planning most commonly have stable preferences for future treatments, further research in real-world settings is needed to confirm the utility of advance care plans for future decision making.
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Affiliation(s)
- Catherine L Auriemma
- University of Pennsylvania Perelman School of Medicine, Philadelphia2Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia
| | - Christina A Nguyen
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia3Harvard College, Harvard University, Cambridge, Massachusetts4Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman
| | - Rachel Bronheim
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia5Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, New Jersey
| | - Saida Kent
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia
| | - Shrivatsa Nadiger
- Department of Medicine, Presbyterian Hospital, Philadelphia, Pennsylvania
| | - Dustin Pardo
- Department of Medicine, Einstein/Montefiore Medical Center, New York, New York
| | - Scott D Halpern
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia4Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia8Division of Pulmonary, Aller
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Laws MB, Lee Y, Rogers WH, Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Moore R, Wilson IB. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. AIDS Behav 2014; 18:1279-87. [PMID: 24464408 PMCID: PMC4047172 DOI: 10.1007/s10461-014-0697-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.
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Affiliation(s)
- M Barton Laws
- Department of Health Services, Policy and Practice, Brown University, G-S121-7, Providence, RI, 02912, USA,
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Pentz RD, Flamm AL. Code status discussion: just have one. Cancer 2013; 119:1938-40. [PMID: 23564437 DOI: 10.1002/cncr.27983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 12/21/2022]
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012; 125:1928-52. [PMID: 22392529 PMCID: PMC3893703 DOI: 10.1161/cir.0b013e31824f2173] [Citation(s) in RCA: 600] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med 2011; 26:791-7. [PMID: 21286839 PMCID: PMC3138592 DOI: 10.1007/s11606-011-1632-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/16/2010] [Accepted: 12/27/2010] [Indexed: 12/11/2022]
Abstract
Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.
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Downar J, Luk T, Sibbald RW, Santini T, Mikhael J, Berman H, Hawryluck L. Why do patients agree to a "Do not resuscitate" or "Full code" order? Perspectives of medical inpatients. J Gen Intern Med 2011; 26:582-7. [PMID: 21222172 PMCID: PMC3101966 DOI: 10.1007/s11606-010-1616-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 11/01/2010] [Accepted: 12/07/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia. CONCLUSION Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.
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Affiliation(s)
- James Downar
- Department of Medicine, University of Toronto, 200 Elizabeth St. 9N-926, Toronto M5G 2C4, Canada.
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End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract 2011; 61:e49-62. [PMID: 21401993 DOI: 10.3399/bjgp11x549018] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Current models of end-of-life care (EOLC) have been largely developed for cancer and may not meet the needs of heart failure patients. AIM To review the literature concerning conversations about EOLC between patients with heart failure and healthcare professionals, with respect to the prevalence of conversations; patients' and practitioners' preferences for their timing and content; and the facilitators and blockers to conversations. DESIGN OF STUDY Systematic literature review and narrative synthesis. METHOD Searches of Medline, PsycINFO and CINAHL databases from January 1987 to April 2010 were conducted, with citation and journal hand searches. Studies of adult patients with heart failure and/or their health professionals concerning discussions of EOLC were included: discussion and opinion pieces were excluded. Extracted data were analysed using NVivo, with a narrative synthesis of emergent themes. RESULTS Conversations focus largely on disease management; EOLC is rarely discussed. Some patients would welcome such conversations, but many do not realise the seriousness of their condition or do not wish to discuss end-of-life issues. Clinicians are unsure how to discuss the uncertain prognosis and risk of sudden death; fearing causing premature alarm and destroying hope, they wait for cues from patients before raising EOLC issues. Consequently, the conversations rarely take place. CONCLUSION Prognostic uncertainty and high risk of sudden death lead to EOLC conversations being commonly avoided. The implications for policy and practice are discussed: such conversations can be supportive if expressed as 'hoping for the best but preparing for the worst'.
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Loertscher LL, Beckman TJ, Cha SS, Reed DA. Code status discussions: agreement between internal medicine residents and hospitalized patients. TEACHING AND LEARNING IN MEDICINE 2010; 22:251-256. [PMID: 20936570 DOI: 10.1080/10401334.2010.512537] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Medical residents frequently participate in code status discussions, yet their competency in this role has not been evaluated. PURPOSE The objective is to determine the quality of code status discussions from the perspective of both resident and patient. METHODS We conducted a cross-sectional survey of consecutive pairs of hospitalized patients and admitting residents at Mayo Clinic in March 2007. We measured perceptions of occurrence and content of code status discussions, admission volume, and demographic information. RESULTS Among the 41 matched pairs, residents and patients agreed that a code status conversation occurred in 63% of cases. Agreement was more likely if residents performed less than 4 admissions (p= .02). Patients reported the inclusion of specific discussion components, such as resuscitation procedures (7%) and outcomes (0%), less frequently than residents (71% and 27%, respectively, p< .001). CONCLUSIONS Residents and patients demonstrated poor agreement on the occurrence and components of code status conversations. Residency programs should identify ways to enhance residents' competency in eliciting patients' code status preferences and provide adequate time for code status discussions.
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Conn R, Berry PA. The decision to engage in end-of-life discussions: a structured approach for doctors in training. Clin Med (Lond) 2010; 10:468-71. [PMID: 21117379 PMCID: PMC4952408 DOI: 10.7861/clinmedicine.10-5-468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Engaging in end-of-life discussions is a major source of anxiety for doctors in training. The authors propose the use of a decision-making model to assist trainees and their clinical supervisors in such situations. Divided into' 'patient-centred' and 'physician-centred' components, the model ensures that the following aspects are analysed: patient and family safety, patient and family choice, physician competence and physician comfort. A real but historical end-of-life scenario is presented to a foundation year 1 doctor, and the particular risks of engaging in a discussion are subsequently clarified with reference to each of the model's components.
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Biola H, Sloane PD, Williams CS, Daaleman TP, Zimmerman S. Preferences versus practice: life-sustaining treatments in last months of life in long-term care. J Am Med Dir Assoc 2010; 11:42-51. [PMID: 20129214 DOI: 10.1016/j.jamda.2009.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/18/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST. DESIGN AND PARTICIPANTS After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility. SETTING The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states. MEASUREMENTS Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that. RESULTS Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034). CONCLUSION Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.
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Affiliation(s)
- Holly Biola
- Geriatrics Division, Department of Medicine, Duke University, Durham, NC, USA.
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Garrett DD, Tuokko H, Stajduhar KI, Lindsay J, Buehler S. Planning for End-of-Life Care: Findings from the Canadian Study of Health and Aging. Can J Aging 2010. [DOI: 10.3138/cja.27.1.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RÉSUMÉLes étapes utilisées pour l'officialisation des préférences en matière de soins en fin de vie et les facteurs en rapport avec ces étapes sont flous dans la documentation. À l'aide des données de la troisième phase de l'Étude sur la santé et le vieillissement au Canada (ESVC-3), nous avons examiné les relations entre les prédicteurs démographiques et en matière de santé, et les trois résultats (à savoir si les participants avaient réfléchi à leurs préférences de fin de vie, s'ils en avaient discuté, ou s'ils les avaient officialisées), et s'il y avait des relations entre les trois résultats. La région de résidence au Canada, le sexe féminin, et davantage d'années de scolarité étaient des facteurs associés à des personnes ayant réfléchi à leurs préférences. La région de résidence, le sexe féminin, et le manque de déficience cognitive étaient associés aux discussions en matière de préférences, et la région de résidence et le fait de ne pas avoir de conjoint étaient associés au dépôt de documents officiels. Les résidents de l'Ontario étaient les plus enclins à avoir réfléchi à leurs préférences, à en avoir discuté, et à les avoir officialisées, tandis que les résidents des Maritimes étaient les moins enclins à y avoir pensé et à avoir agi en conséquence. Enfin, avoir réfléchi à leurs préférences était associé au fait d'en discuter, et y avoir réfléchi et en avoir discuté étaient chacun associés à l'officialisation des préférences. Ces résultats correspondent au postulat que l'exécution du mandat (directive par procuration) est un processus comportant plusieurs étapes. Avoir une meilleure idée de ce processus peut se révéler utile lors de l'élaboration d'interventions visant à promouvoir la planification des soins en fin de vie.
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Savory EA, Marco CA. End-of-life issues in the acute and critically ill patient. Scand J Trauma Resusc Emerg Med 2009; 17:21. [PMID: 19386133 PMCID: PMC2678074 DOI: 10.1186/1757-7241-17-21] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 04/22/2009] [Indexed: 11/24/2022] Open
Abstract
The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.
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Affiliation(s)
- Eric A Savory
- University of Toledo College of Medicine, Mail Stop 1114, 3045 Arlington Avenue, Toledo, Ohio 43614, USA
| | - Catherine A Marco
- Professor, Department of Surgery, Emergency Medicine, Director of Medical Ethics Curriculum, University of Toledo College of Medicine, Mail Stop 1114, 3045 Arlington Avenue, Toledo, Ohio 43614, USA
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Clayton JM, Hancock KM, Butow PN, Tattersall MHN, Currow DC, Adler J, Aranda S, Auret K, Boyle F, Britton A, Chye R, Clark K, Davidson P, Davis JM, Girgis A, Graham S, Hardy J, Introna K, Kearsley J, Kerridge I, Kristjanson L, Martin P, McBride A, Meller A, Mitchell G, Moore A, Noble B, Olver I, Parker S, Peters M, Saul P, Stewart C, Swinburne L, Tobin B, Tuckwell K, Yates P. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007; 186:S77-S105. [PMID: 17727340 DOI: 10.5694/j.1326-5377.2007.tb01100.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 03/18/2007] [Indexed: 11/17/2022]
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Barclay JS, Blackhall LJ, Tulsky JA. Communication Strategies and Cultural Issues in the Delivery of Bad News. J Palliat Med 2007; 10:958-77. [PMID: 17803420 DOI: 10.1089/jpm.2007.9929] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.
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Affiliation(s)
- Joshua S Barclay
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705-3860, USA.
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Ramón I, Alonso J, Subirats E, Yáñez A, Santed R, Pujol R. El lugar de fallecimiento de las personas ancianas en Cataluña. Rev Clin Esp 2006; 206:549-55. [PMID: 17178074 DOI: 10.1157/13096302] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To describe the place of death of the elderly and to analyze the factors associated with death occurring in an acute care hospital. DESIGN Cross-sectional interview of a randomized sample of individuals aged 65 or over who died during the year 1998. Three to four months after the death of the elderly subject, the main caregiver was interviewed about the socio-demographic characteristics, chronic conditions, functional and cognitive status, and use of health services in the months previous to the death, as well as the place where death occurred and their preferences on this site. SETTING Six areas of Catalonia, Spain, differing in the level of health and end of life social services. PARTICIPANTS 584 caregivers (78.6% response rate). MAIN RESULTS Mean age of the deceased elderly was 81.4 (+/- 8) and half of them were females. 52% (95% CI: 47.5-55.7) had died in acute care hospitals. 35% of the caregivers of those dying at an acute hospital reported that they would have preferred another place for death. After adjustment, variables associated with dying in acute care hospitals were: living in an area with lower availability of social and health services for the end of life (OR: 2.8; 95% CI: 1.4-5.5) and suffering from chronic obstructive pulmonary disease (OR: 1.7; 95% CI: 1.1-2.5). CONCLUSIONS Acute hospitals are the predominant place of death in Catalonia, Spain. The place of death seems to be more closely influenced by the availability of end-of-life care services. There is a clear preference for dying at an alternative place to acute hospitals.
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Affiliation(s)
- I Ramón
- Hospital General de Vic, Barcelona, España
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Abstract
Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, Acute Care Services, St Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Palliat Med 2006; 9:451-63. [PMID: 16629574 DOI: 10.1089/jpm.2006.9.451] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values. OBJECTIVE To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes. DESIGN Thematic literature review. RESULTS The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death. CONCLUSIONS Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.
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Affiliation(s)
- Joseph S Weiner
- Long Island Jewish Medical Center, Departments of Medicine and Psychiatry, New Hyde Park, NY 11040, USA.
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Abstract
The interrelationships between biomedical ethics and the law are perhaps nowhere as starkly apparent as in the realm of medical malpractice. Although ethical and legal conduct and practices are often in harmony, in many areas ethical principles and the issues surrounding medical liability appear to come into conflict. Disclosure of errors; quality improvement activities; the practice of defensive medicine; dealing with patients who wish to leave against medical advice; provision of futile care at the insistence of patients or families; and the various protections of Good Samaritan laws are just a few of these. In addition, the ethical principles governing the conduct of physicians serving as expert witnesses in medical malpractice cases have become a subject of intense interest in recent years.
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Laakkonen ML, Pitkala KH, Strandberg TE, Berglind S, Tilvis RS. Older people's reasoning for resuscitation preferences and their role in the decision-making process. Resuscitation 2005; 65:165-71. [PMID: 15866396 DOI: 10.1016/j.resuscitation.2004.11.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Revised: 09/29/2004] [Accepted: 11/13/2004] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To investigate older patients' reasoning for their cardiopulmonary resuscitation (CPR) preferences and the related decision-making process (DMP). METHODS AND SUBJECTS In a descriptive study 220 elderly home-dwelling cardiovascular patients were interviewed and asked to justify their CPR preferences according to the given statements. Questions related to DMP were asked and their physical function, cognition, mood, and quality of life were assessed. RESULTS Resuscitation preferences were associated with several patient characteristics, such as age, mood and quality of life. Patients preferring CPR (114/220, 52%) estimated their prognosis of CPR to be better than those preferring to forgo CPR. They justified their view: "Life is precious and worth living for me" (92%), "Maintaining life is a value of its own" (92%), "I feel needed by my family and my closest" (81%). Participants preferring to forgo CPR (106/220, 48%) justified: "I have already gained old age and led a full life" (88%), "People cannot decide these things" (72%). Only 9% of patients had discussed, and 38% would like to discuss preferences for life-sustaining treatments (LSTs) with their physician. However, 80% of respondents felt that the patients should take some part in the DMP; either alone (9%), together with a physician (23%), or together with a physician and a close relative (48%). CONCLUSIONS Older people justify their resuscitation preferences highlighting their experiences of meaningful life or fulfillment of their life, interpersonal relationships with their loved ones and presumed outcome of CPR. Less than a half of the patients wished to discuss CPR and LSTs preferences in their current situation with their physician, but nevertheless wanted to participate in the DMP of end-of-life treatment. Physicians should assess patients' own preferences in-depth.
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Marco CA, Buderer N, Thum SD. End-of-life care: perspectives of family members of deceased patients. Am J Hosp Palliat Care 2005; 22:26-31. [PMID: 15736604 DOI: 10.1177/104990910502200108] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study was undertaken to determine the opinions of family members of deceased patients regarding end-of-life care. This multisite cross-sectional survey was administered to 969 volunteer participants during 1997 to 2000. Eligible participants included immediate family members of deceased patients at five local institutions in a regional health system. Among 969 respondents, most (84.4 percent) indicated that the care for their family member was excellent. Reasons cited for satisfaction included overall care (40.2 percent), staff effort (23.2 percent), and communication (16.4 percent). Reasons cited for dissatisfaction included perceived incompetence (9.7 percent), perceived uncaring attitude (8.4 percent), and perceived understaffing (3.7 percent). Respondents were more satisfied with communication from nursing staff (88 percent) than physicians' communication (78 percent, p < 0.001, Bowker's test). Respondents indicated higher overall satisfaction with nursing (90 percent) and pastoral care (87 percent), than with physician care (81 percent, p < 0.001 and p = 0.006, Bowker's test). A unique survey instrument can be used to measure family perceptions and opinions regarding end-of-life care.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
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Abstract
UNLABELLED There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU). HYPOTHESIS Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU. PATIENTS AND METHODS A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months. RESULTS Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001). CONCLUSIONS Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.
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Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Scottsdale, Phoenix, AZ 85054, USA
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Engelberg RA. Commentary: observational studies and their importance in improving end-of-life care in the intensive care unit. J Crit Care 2003; 18:141-4. [PMID: 14626210 DOI: 10.1016/j.jcrc.2003.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ruth A Engelberg
- Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Washington Seatle, WA 98104-2499, USA.
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Gallo JJ, Straton JB, Klag MJ, Meoni LA, Sulmasy DP, Wang NY, Ford DE. Life-sustaining treatments: what do physicians want and do they express their wishes to others? J Am Geriatr Soc 2003; 51:961-9. [PMID: 12834516 DOI: 10.1046/j.1365-2389.2003.51309.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN Mailed survey to a cohort of physicians. SETTING Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.
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Affiliation(s)
- Joseph J Gallo
- Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Chaitin E, Stiller R, Jacobs S, Hershl J, Grogen T, Weinberg J. Physician-patient relationship in the intensive care unit: erosion of the sacred trust? Crit Care Med 2003; 31:S367-72. [PMID: 12771585 DOI: 10.1097/01.ccm.0000066452.48589.f4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With the advent of the increasing technology and multispecialty medicine, the strong relationship or "sacred trust" between patient and family physician has gradually eroded. Various subspecialists are now entrusted with patient care at different phases of evaluation and treatment. Because of the transient nature of these physician-patient interactions, a strong bond is often not established before critical decisions must be made concerning ongoing patient care. As a result, multiple members of the different healthcare teams (the care cooperative) may be confronted with addressing end-of-life discussions, which in the past was the responsibility of the primary physician. Because of this need to move into a previously viewed private territory, communication conflicts may arise between members of the healthcare team. In an effort to understand and deal with observed recurrent problems that occurred when patient care was transferred between specialty care teams, our institution has addressed communication conflicts that arise in the care of oncology patients transferred to the intensive care unit. Our goal has been to initiate and maintain a dialog to avoid misunderstandings and to reduce anxiety between members of the intensivist and oncology services. To this end, we have addressed the various pitfalls that come with the transition from the traditional physician-patient relationship to the more fluid and comprehensive care-cooperative mode. We believe this approach to be useful in improving communication between healthcare providers in the multispecialty care setting, which will ultimately enhance the quality of patient care.
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Baker DW, Einstadter D, Husak S, Cebul RD. Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act. J Gen Intern Med 2003; 18:343-9. [PMID: 12795732 PMCID: PMC1494855 DOI: 10.1046/j.1525-1497.2003.20522.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine changes in the use of do-not-resuscitate (DNR) orders and mortality rates following a DNR order after the Patient Self-determination Act (PSDA) was implemented in December 1991. DESIGN Time-series. SETTING Twenty-nine hospitals in Northeast Ohio. PATIENTS/PARTICIPANTS Medicare patients (N = 91,539) hospitalized with myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. MEASUREMENTS AND MAIN RESULTS The use of "early" (first 2 hospital days) and "late" DNR orders was determined from chart abstractions. Deaths within 30 days after a DNR order were identified from Medicare Provider Analysis and Review files. Risk-adjusted rates of early DNR orders increased by 34% to 66% between 1991 and 1992 for 4 of the 6 conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29% to 53% for 4 of the 6 conditions between 1991 and 1997. Risk-adjusted mortality during the 30 days after a DNR order was written did not change between 1991 and 1997 for 5 conditions, but risk-adjusted mortality increased by 21% and 25% for stroke patients with early DNR and late DNR orders, respectively. CONCLUSIONS Overall use of DNR orders changed relatively little after passage of the PSDA, because the increase in the use of early DNR orders between 1991 and 1992 was counteracted by decreasing use of late DNR orders. Risk-adjusted mortality rates after a DNR order generally remained stable, suggesting that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the increasing mortality for stroke patients warrants further examination.
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Affiliation(s)
- David W Baker
- Center for Health Care Research and Policy and Department of Medicine ,Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio, USA.
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Affiliation(s)
- Ann M Butterworth
- Senior Campus Physician's Group, Charlestown Erickson Retirement Community, Baltimore, MD, USA
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Abstract
Most physicians believe they do more good than harm, and these duties of helping and not harming the patient are rooted in the Hippocratic oath, the good Samaritan tradition, and the Order of the Knight Hospitallers founded in the 11th century to care for pilgrims and those wounded in the Crusades.(1) In recent times the simple principles of beneficence and non-maleficence have been augmented and sometimes challenged by a rising awareness of patient/consumer rights, and the public expectation of greater involvement in medical, social and scientific affairs which affect them. In a publicly funded healthcare system in which rationing (explicit or otherwise) is inevitable, the additional concepts of utility and distributive justice can easily come into conflict with the individual's right to autonomy. Possible treatment options for end stage lung disease include transplantation and long term invasive ventilation which are challenging in resource terms. Other interventions such as pulmonary rehabilitation and palliative care are relatively low cost but not uniformly accessible.
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Affiliation(s)
- A K Simonds
- Sleep and Ventilation Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Meier DE. When pain and suffering do not require a prognosis: working toward meaningful hospital-hospice partnership. J Palliat Med 2003; 6:109-15. [PMID: 12710583 DOI: 10.1089/10966210360510226] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Drought TS, Koenig BA. "Choice" in end-of-life decision making: researching fact or fiction? THE GERONTOLOGIST 2002; 42 Spec No 3:114-28. [PMID: 12415142 DOI: 10.1093/geront/42.suppl_3.114] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The contribution of bioethics to clinical care at the end of life (EOL) deserves critical scrutiny. We argue that researchers have rarely questioned the normative power of autonomy-based bioethics practices. Research on the ethical dimensions of EOL decision making has focused on an idealized discourse of patient "choice" that requires patients to embrace their dying to receive excellent palliative care. DESIGN AND METHODS Our critique is based on a comprehensive review of empirical research exploring bioethics practices at the EOL. In addition we will provide a brief review of our own ethnographic, longitudinal study of the decision-making experience of dying patients, their families, and their health care providers. RESULTS There is little or no empirical evidence to support the autonomy paradigm of patient "choice" in EOL decision making. What we found is that (a). prognostication at the EOL is problematic and resisted; (b). shared decision making is illusory, patients often resist advance care planning and hold other values more important than autonomy, and system characteristics are more determinative of EOL care than patient preferences; and (c). the incommensurability of medical and lay knowledge and values and the multifaceted and processual nature of patient and family decision making are at odds with the current EOL approach toward advance care planning. IMPLICATIONS It is exceedingly difficult to identify, study, and critique normative assumptions without creating them, reproducing them, or obliterating them in the process. However, a fuller account of the morally significant domains of end-of-life care is needed. Researchers and policy makers should heed what we have learned from empirical research on EOL care to develop more sensitive and supportive programs for care of the dying.
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