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Termoz A, Subtil F, Drouin P, Marchal M, Verroul M, Langlois C, Bravant E, Jacquin L, Clément B, Viglino D, Roux-Boniface D, Verbois F, Demarquet M, Dubucs X, Douillet D, Tazarourte K, Schott-Pethelaz AM, Haesebaert J, Douplat M. Evaluating the impact of a standardised intervention for announcing decisions of withholding and withdrawing life-sustaining treatments on the stress of relatives in emergency departments (DISCUSS): protocol for a stepped-wedge randomised controlled trial. BMJ Open 2024; 14:e087444. [PMID: 39237283 PMCID: PMC11381699 DOI: 10.1136/bmjopen-2024-087444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives. METHODS AND ANALYSIS The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days. ETHICS AND DISSEMINATION This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT06071078.
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Affiliation(s)
- Anne Termoz
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Fabien Subtil
- Pôle Santé Publique, Service de Biostatistique et Bio-informatique, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Pauline Drouin
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Mathilde Marchal
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Manon Verroul
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Carole Langlois
- Pôle Santé Publique, Service de Biostatistique et Bio-informatique, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Estelle Bravant
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Laurent Jacquin
- Hôpital Edouard Herriot, Service d'Accueil des Urgences, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Bénédicte Clément
- Hôpital de la Croix-Rousse, Service d'Accueil des Urgences, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Damien Viglino
- Hôpital Nord, Service d'Accueil des Urgences, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Daniel Roux-Boniface
- Hôpital Gabriel Montpied, Service d'Accueil des Urgences, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Frédéric Verbois
- Centre Hospitalier Nord Ouest, Service d'Accueil des Urgences, Hopital de Villefranche-sur-Saone, Villefranche-sur-Saone, Auvergne-Rhône-Alpes, France
| | - Marine Demarquet
- Centre Hospitalier Fleyriat, Service d'Accueil des Urgences, Centre Hospitalier de Bourg-en-Bresse, Bourg-en-Bresse, Rhône-Alpes, France
| | - Xavier Dubucs
- Hôpital Larrey, Service d'Accueil des Urgences, Centre Hospitalier Universitaire de Toulouse, Toulouse, Occitanie, France
| | - Delphine Douillet
- Hôpital Larrey, Service d'Accueil des Urgences, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Karim Tazarourte
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Hôpital Edouard Herriot, Service d'Accueil des Urgences, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Anne-Marie Schott-Pethelaz
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Julie Haesebaert
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Marion Douplat
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1-Domaine de Rockefeller, Lyon, Rhône-Alpes, France
- Hôpital Lyon Sud, Service d'Accueil des Urgences, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024; 37:805-817. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Levy-Malmberg R, Boman E, Lehwaldt D, Fagerström L, Lockwood EB. Clinical decision-making processes among graduate nurses, specialist nurses and nurse practitioners A collaborative international study. Int Nurs Rev 2024; 71:224-231. [PMID: 38450783 DOI: 10.1111/inr.12951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/08/2024] [Indexed: 03/08/2024]
Abstract
AIM To explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. BACKGROUND Clinical decision-making in an emergency department environment is a complex process often occurring in times of crisis. It is an important aspect contributing to the quality of care. However, empirical research is limited regarding the decision-making process in different nursing roles. METHODS In accordance with the consolidated criteria for reporting qualitative research, a qualitative and observational study was conducted to explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Six Registered Nurses, six Nurse Specialists and six Nurse Practitioners were observed. A total of 40 hours of observation was made at each setting according to a structured observation guideline, followed by clarifying questions. The data material was analysed by means of a qualitative manifest and latent content analysis. RESULTS Three themes arose: acting in accordance with routines, previous experience and intuition; considering patient experience; and facilitating new alternatives based on critical thinking. The Registered Nurses mainly used the first approach, the Nurse Specialists used the first and the second approaches, and the Nurse Practitioners used all three approaches. CONCLUSIONS The results highlight the differences in decision-making processes between these groups. Nurse Practitioners were the only group that facilitated and evaluated new alternatives using their clinical autonomy, such as stepping up and making independent and collaborative decision-making. IMPLICATION The results can be used in countries developing advanced practice nursing education and defining their scope of practice to inform stakeholders.
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Affiliation(s)
- Rika Levy-Malmberg
- University of South-Eastern Norway, Kongsberg, Norway
- Novia University of Applied Sciences, Vaasa, Finland
| | - Erika Boman
- University of South-Eastern Norway, Kongsberg, Norway
- Åland University of Applied Sciences, Mariehamn, Finland
| | - Daniela Lehwaldt
- Dublin City University, School of Nursing, Psychotherapy & Community Health, Dublin, Ireland
| | - Lisbeth Fagerström
- University of South-Eastern Norway, Kongsberg, Norway
- Åbo Akademi University, Vaasa, Finland
| | - Emily B Lockwood
- University College Cork, School of Nursing and Midwifery, Cork, Ireland
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Dorsemans AC, Coarelli G, Heinzmann A, Verdon B, De Luca M, Petit E, Pierron L, Levy-Soussan M, Durr A, Gargiulo M, Ewenczyk C. End-of-Life Discussions With Patients and Caregivers Affected By Neurogenetic Diseases. Neurol Clin Pract 2023; 13:e200199. [PMID: 37854177 PMCID: PMC10581072 DOI: 10.1212/cpj.0000000000200199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 09/06/2023] [Indexed: 10/20/2023]
Abstract
Background and Objectives No effective cure is available for neurogenetic diseases such as Huntington disease, spinocerebellar ataxias, and Friedreich ataxia, all of which cause progressive motor, cognitive, and psychiatric symptoms leading, in the long term, to severe communication (among other) impairments. In end-of-life situations, advanced directives (indications formulated by the patient about end-of-life choices) are one decision-making resource for relatives, caregivers, and health care professionals. Given the slowly progressive nature of these diseases, the related disabilities, and their hereditary component, patients, caregivers, and neurologists are often at a loss concerning the right course of action to take. Our study's aim was to explore patients' and caregivers' perceptions, needs, and expectations around anticipated end-of-life discussions and advanced directives. Methods DIRAGENE is an observational, cross-sectional, mixed-methods study with a patient-centered component and a primary caregiver-centered component. Observations include disease severity, psychosocial, and emotional scales; in-house questionnaires; and semidirected interviews. Results We included 124 participants, of which 81 were patients and 43 primary caregivers. Only 16% of the participants knew specifically about advanced directives and 7% had written documents vs 30% and 18% in the general French population, respectively, adjusted for age. Qualitative analysis of the interviews with 15 couples showed notable dissimilarities in ideas about advanced directives between patients and caregivers and that the underlying pathology, severity, and inheritability are less relevant factors regarding end-of-life discussions than age, environment, prior experiences with death, and history of family illness. Most patients (95%) and caregivers (98%) found that participating in the study was helpful in bringing awareness to end-of-life issues, wished to prioritize discussing them with loved ones, and requested assistance in managing them throughout the course of the disease. Discussion Being affected by severe neurogenetic diseases does not seem to prompt individuals to give much thought to end-of-life planning. However, patients and caregivers welcome comprehensive information and expect progressive support from trained health care professionals in having such discussions. Routine integration of these conversations into medical management through a holistic and adapted approach will benefit patients with illnesses with unfavorable long-term prognoses.
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Affiliation(s)
- Anne-Claire Dorsemans
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Giulia Coarelli
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Anna Heinzmann
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Benoit Verdon
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Manuella De Luca
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Elodie Petit
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Lucie Pierron
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Michèle Levy-Soussan
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Alexandra Durr
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Marcela Gargiulo
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
| | - Claire Ewenczyk
- Sorbonne Université (A-CD, GC, AH, EP, AD, CE), Paris Brain Institute (ICM Institut du Cerveau), APHP, INSERM, CRNS; Université Paris Cité (A-CD, BV, MDL, MG), Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt; Genetic Department (GC, AH, LP, MG, CE), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Mobile Palliative Care Unit (ML-S), Pitié-Salpêtrière Charles-Foix University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP); Université Paris Cité (ML-S), Team Science, Normes, Démocratie, SND UMR 8011, Sorbonne Université Lettres; and Institute of Myology (MG), Pitié-Salpêtrière University Hospital, Paris, France
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Rambaud S, Gavoille A, Economos G, Tazarourte K, Douplat M. Decision-making process of withholding or withdrawing life-sustaining treatments in French emergency departments during COVID-19 outbreak. Eur J Emerg Med 2023; 30:371-373. [PMID: 37650740 DOI: 10.1097/mej.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Severin Rambaud
- Emergency Department, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre Bénite
| | - Antoine Gavoille
- Service de Biostatistique, Hospices Civils de Lyon, Lyon
- Université de Lyon Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne
| | - Guillaume Economos
- Palliative Care Center, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre Bénite
- Université Claude Bernard Lyon 1, EA 3738 - CICLy, Centre d'Innovation en Cancérologie de Lyon, UFR Faculté de Médecin Lyon-Sud-Charles Mérieux BP1
| | - Karim Tazarourte
- Emergency Department, Edouard Herriot Hospital, Hospices Civils de Lyon
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon
| | - Marion Douplat
- Emergency Department, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre Bénite
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon
- UMR ADéS 7268, Aix-Marseille University/EFS/CNRS, Espace éthique méditerranéen, Marseille, France
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Tiah L, Chua MT, Kuan WS, Tan A, Tay E, Yash Pal R, Dong C. Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis. Medicina (B Aires) 2023; 59:medicina59030456. [PMID: 36984457 PMCID: PMC10053832 DOI: 10.3390/medicina59030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.
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Affiliation(s)
- Ling Tiah
- Accident & Emergency Department, Changi General Hospital, Singapore Health Services, Singapore 529889, Singapore
- Correspondence:
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Alina Tan
- Department of Anesthesia, National University Hospital, National University of Singapore, Singapore 119074, Singapore
| | - Eileen Tay
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Chaoyan Dong
- Education Office, Sengkang General Hospital, Singapore Health Services, Singapore 554886, Singapore
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Douplat M, Gavoille A, Subtil F, Haesebaert J, Jacquin L, Durand G, Lega JC, Perpoint T, Potinet V, Berthiller J, Perreton N, Tazarourte K. Management and Outcome of COVID-19 Positive and Negative Patients in French Emergency Departments During the First COVID-19 Outbreak: A Prospective Controlled Cohort Study. West J Emerg Med 2022; 23:897-906. [DOI: 10.5811/westjem.2022.7.57135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/19/2022] [Indexed: 11/15/2022] Open
Abstract
ntroduction: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs.
Methods: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6–May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status.
Results: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P <0.001), and they required mechanical ventilation (89, 11.9% vs 37, 1.9%; P <0.001) and high-flow nasal cannula oxygen therapy (135, 18.1% vs 41, 2.2%; P < 0.001) more frequently. The in-hospital mortality was significantly higher among COVID-19 positive patients (139, 18.3% vs 149, 7.7%; P <0.001).
Conclusion: Emergency departments were on the frontline during the COVID-19 pandemic and had to manage potential COVID-19 patients. Understanding what happened in the ED during this first outbreak is crucial to underline the importance of flexible organizations that can quickly adapt the bed capacities to the incoming flow of COVID-19 positive patients.
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Affiliation(s)
- Marion Douplat
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Hospices Civils de Lyon, Lyon Sud Hospital, Department of Emergency Medicine, Pierre Bénite, France
| | - Antoine Gavoille
- Université de Lyon Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France; Service de Biostatistique, Hospices Civils de Lyon, Lyon France
| | - Fabien Subtil
- Université de Lyon Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France; Service de Biostatistique, Hospices Civils de Lyon, Lyon France
| | - Julie Haesebaert
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Pôle de Santé Publique, Service de Recherche et d’Epidémiologie Cliniques, Hospices Civils de Lyon, France
| | - Laurent Jacquin
- Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Emergency Medicine, Lyon, France
| | - Guillaume Durand
- Villefranche Hospital, Department of Emergency Medicine, Gleize, France
| | - Jean-Christophe Lega
- Hospices Civils de Lyon, Lyon Sud Hospital, Department of Internal and Vascular Medicine, Pierre Bénite, France
| | - Thomas Perpoint
- Service de Maladies Infectieuses et Tropicales, Hôpital Croix-Rousse Hospices Civils de Lyon, Lyon, France
| | - Veronique Potinet
- Hospices Civils de Lyon, Lyon Sud Hospital, Department of Emergency Medicine, Pierre Bénite, France
| | - Julien Berthiller
- Pôle de Santé Publique, Service de Recherche et d’Epidémiologie Cliniques, Hospices Civils de Lyon, France
| | - Nathalie Perreton
- Pôle de Santé Publique, Service de Recherche et d’Epidémiologie Cliniques, Hospices Civils de Lyon, France
| | - Karim Tazarourte
- Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Emergency Medicine, Lyon, France
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8
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Smadja DM, Fellous BA, Bonnet G, Hauw-Berlemont C, Sutter W, Beauvais A, Fauvel C, Philippe A, Weizman O, Mika D, Juvin P, Waldmann V, Diehl JL, Cohen A, Chocron R. D-dimer, BNP/NT-pro-BNP, and creatinine are reliable decision-making biomarkers in life-sustaining therapies withholding and withdrawing during COVID-19 outbreak. Front Cardiovasc Med 2022; 9:935333. [PMID: 36148049 PMCID: PMC9485619 DOI: 10.3389/fcvm.2022.935333] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background The decision for withholding and withdrawing of life-sustaining treatments (LSTs) in COVID-19 patients is currently based on a collegial and mainly clinical assessment. In the context of a global pandemic and overwhelmed health system, the question of LST decision support for COVID-19 patients using prognostic biomarkers arises. Methods In a multicenter study in 24 French hospitals, 2878 COVID-19 patients hospitalized in medical departments from 26 February to 20 April 2020 were included. In a propensity-matched population, we compared the clinical, biological, and management characteristics and survival of patients with and without LST decision using Student's t-test, the chi-square test, and the Cox model, respectively. Results An LST was decided for 591 COVID-19 patients (20.5%). These 591 patients with LST decision were secondarily matched (1:1) based on age, sex, body mass index, and cancer history with 591 COVID-19 patients with no LST decision. The patients with LST decision had significantly more cardiovascular diseases, such as high blood pressure (72.9 vs. 66.7%, p = 0.02), stroke (19.3 vs. 11.1%, p < 0.001), renal failure (30.4 vs. 17.4%, p < 0.001), and heart disease (22.5 vs. 14.9%, p < 0.001). Upon admission, LST patients were more severely attested by a qSOFA score ≥2 (66.5 vs. 58.8%, p = 0.03). Biologically, LST patients had significantly higher values of D-dimer, markers of heart failure (BNP and NT-pro-BNP), and renal damage (creatinine) (p < 0.001). Their evolutions were more often unfavorable (in-hospital mortality) than patients with no LST decision (41.5 vs. 10.3%, p < 0.001). By combining the three biomarkers (D-dimer, BNP and/or NT-proBNP, and creatinine), the proportion of LST increased significantly with the number of abnormally high biomarkers (24, 41.3, 48.3, and 60%, respectively, for none, one, two, and three high values of biomarkers, trend p < 0.01). Conclusion The concomitant increase in D-dimer, BNP/NT-proBNP, and creatinine during the admission of a COVID-19 patient could represent a reliable and helpful tool for LST decision. Circulating biomarker might potentially provide additional information for LST decision in COVID-19.
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Affiliation(s)
- David M. Smadja
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department, AP-HP, Georges Pompidou European Hospital, Paris, France
- *Correspondence: David M. Smadja
| | - Benjamin A. Fellous
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
| | - Guillaume Bonnet
- Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, Paris, France
- Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Unité Médico-Chirurgical de Valvulopathies et Cardiomyopathies, Pessac, France
| | | | - Willy Sutter
- Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, Paris, France
- Vascular Surgery Department, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Agathe Beauvais
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Emergency Department, AP-HP, Georges Pompidou European Hospital, Paris, France
| | | | - Aurélien Philippe
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Orianne Weizman
- Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, Vandoeuvre les Nancy, France
| | - Delphine Mika
- Université Paris-Saclay, Inserm, UMR-S 1180, Chatenay-Malabry, France
| | - Philippe Juvin
- Emergency Department, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Victor Waldmann
- Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, Paris, France
- Cardiology Department, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Jean-Luc Diehl
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Medical Intensive Care Department AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Ariel Cohen
- Cardiology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Richard Chocron
- Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, Paris, France
- Emergency Department, AP-HP, Georges Pompidou European Hospital, Paris, France
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9
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Petri S, Zwißler B, In der Schmitten J, Feddersen B. [Advance Care Planning-further development of the patient advance directive : What the specialist in internal medicine must know]. Internist (Berl) 2022; 63:533-544. [PMID: 35441880 PMCID: PMC9020146 DOI: 10.1007/s00108-022-01333-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.
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Affiliation(s)
- S Petri
- Caritasverband der Erzdiözese München und Freising e. V., München, Deutschland
| | - B Zwißler
- Klinik für Anästhesiologie, Klinikum der Universität München, LMU München, München, Deutschland
| | - J In der Schmitten
- Institut für Allgemeinmedizin, Universitätsklinik Essen, Essen, Deutschland
| | - B Feddersen
- Klinik und Poliklinik für Palliativmedizin, SAPV, Klinikum der Universität München, LMU München, Schillerstr. 40/III, 80336, München, Deutschland.
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10
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Park SY, Kim H, Park KH, Park SM, Lee DE, Jung YH, Jeong W, Park KH. Exploring the experiences and perspectives of emergency physicians on brain death organ tissue donation after the Life-Sustaining Treatment Decision Act. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:29-36. [PMID: 35769432 PMCID: PMC9235530 DOI: 10.4285/kjt.22.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background This study explored emergency physicians' experiences and perspectives related to brain death organ tissue donation (OTD) after the enforcement of the Life-Sustaining Treatment (LST) Decision Act in Korea. Methods Using the Braun and Clarke thematic analysis method, this qualitative study analyzed interview data-comprising experiences and perspectives of brain death OTD since the LST Decision Act-of 10 emergency physicians who specialized in targeted temperature management (TTM) and cared for post-cardiac arrest patients. Results Data analysis revealed 13 subthemes and 5 themes the LST Decision Act is easier to explain to family members than brain death OTD, but it does not fit well in an emergency medical setting; many family members decide to stop LST even before physicians mention brain death or OTD; family members view stopping LST as being about comforting patients without bothering them, and decision-makers are therefore no longer willing to choose OTD; stopping LST does not always result in brain death, but cases of brain death are preceded by stopping LST; and since the LST Decision Act, the number of TTM cases and potential brain death donors has decreased. Conclusions Unless a supplementary policy that connects stopping LST to brain death OTD is prepared, the withdrawal of LST in patients resuscitated after cardiac arrest is expected to continue, and brain death OTD is expected to decrease.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
- Department of Medical Education, Dong-A University College of Medicine, Busan, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kwi Hwa Park
- Department of Medical Education, Gachon University College of Medicine, Incheon, Korea
| | - Seung Min Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dong Eun Lee
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Hye Park
- Department of Medical Education, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Emergency Medicine, Wonju Severance Christian Hospital, Wonju, Korea
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Douplat M, Fraticelli L, Claustre C, Peiretti A, Serre P, Bischoff M, Jacquin L, Freyssenge J, Schott AM, Tazarourte K, Frugier S, Khoury CEL, Grezard M, Antoine JD, Dumont O, Lhuillier E, Pierro L, Blain S, Prost C, Sen-Brachet P, Khaldi A. Management of decision of withholding and withdrawing life-sustaining treatments in French EDs. Scand J Trauma Resusc Emerg Med 2020; 28:52. [PMID: 32513282 PMCID: PMC7282105 DOI: 10.1186/s13049-020-00744-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature.
Study objective
We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France.
Method
In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process.
Results
There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives.
Conclusion
The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.
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12
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Symptoms of anxiety and depression in relatives after decisions of withholding and withdrawing life-sustaining treatments in emergency departments. Eur J Emerg Med 2020; 27:338-343. [DOI: 10.1097/mej.0000000000000669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Douplat M, Jacquin L, Frugier S, Tazarourte K, Le Coz P. Difficulty of the ethical decision-making process in withholding and withdrawing life-sustaining treatments in French EDs during COVID pandemic. SCANDINAVIAN JOURNAL OF TRAUMA, RESUSCITATION AND EMERGENCY MEDICINE 2020; 28:78. [PMID: 32792005 PMCID: PMC7424240 DOI: 10.1186/s13049-020-00772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Marion Douplat
- Emergency Department, Lyon Sud Hospital, University Hospital, Hospices Civiles of Lyon, 165 chemin du Grand Revoyet, F-69495, Pierre Bénite, France. .,UMR ADéS 7268, Aix-Marseille University/ EFS / CNRS, Espace éthique méditerranéen, Timone Adulte's Hospital, Marseille, France.
| | - Laurent Jacquin
- Emergency Department, Édouard-Herriot Hospital, Lyon University Hospital, Hospices Civiles of Lyon, 5 place d'Arsonval, F-69003, Lyon, France
| | - Soizic Frugier
- Emergency Department, Lyon Sud Hospital, University Hospital, Hospices Civiles of Lyon, 165 chemin du Grand Revoyet, F-69495, Pierre Bénite, France
| | - Karim Tazarourte
- Emergency Department, Édouard-Herriot Hospital, Lyon University Hospital, Hospices Civiles of Lyon, 5 place d'Arsonval, F-69003, Lyon, France
| | - Pierre Le Coz
- UMR ADéS 7268, Aix-Marseille University/ EFS / CNRS, Espace éthique méditerranéen, Timone Adulte's Hospital, Marseille, France
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Douplat M, Daoud K, Berthiller J, Schott AM, Potinet V, Le Coz P, Tazarourte K, Jacquin L. Poor Involvement of General Practitioners in Decisions of Withholding or Withdrawing Life-Sustaining Treatment in Emergency Departments. J Gen Intern Med 2020; 35:177-181. [PMID: 31686289 PMCID: PMC6957665 DOI: 10.1007/s11606-019-05464-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 09/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decisions of withholding or withdrawing life-sustaining treatment are frequent in emergency departments (ED) and patients are often unable to communicate their wishes concerning end of life desires. OBJECTIVE To evaluate the participation of general practitioners (GPs) during the decision-making process of withholding or withdrawing life-sustaining treatments in ED. DESIGN Prospective observational multicenter study. PATIENTS We included patients for whom a decision of withdrawing or withholding life-sustaining treatments was made in ED. For each patient, we enrolled one general practitioner. MAIN MEASURES GPs were interviewed about their perception of end of life patient's management and the communication with ED and families. KEY RESULTS There were 109 potential patient participants. We obtained answers from 54 (49.5%) of the patient's associated GPs. Only 4 (7.4%) GPs were involved during the decision-making process of withholding or withdrawing life-sustaining treatments. Among GPs, 29 (53.7%) were contacted by family after the decision, most often to talk about their difficult experience with the decision. A majority (94%) believed their involvements in these decisions were important and 68% wished to "always" participate in end of life decisions despite the fact that they usually don't participate in these decisions. Finally, 66% of GPs believed that management of end of life in the emergency department was a failure and should be anticipated. CONCLUSIONS GPs would like to be more involved and barriers to GP involvement need to be overcome. We do not have any outcome data to suggest that routine involvement of GPs in all end of life patients improves their outcomes. Moreover, it requires major system and process-based changes to involve all primary care physicians in ED decision-making. NIH TRIAL REGISTRY NUMBER NCT02844972.
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Affiliation(s)
- Marion Douplat
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d’Accueil des urgences, 165 chemin du Grand Revoyet, F-69495 Pierre Bénite, France
- Aix-Marseille Université/EFS/CNRS, UMR 7268 ADéS, Faculté de Médecine, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Khadidja Daoud
- Hôpital de Vienne, Service d’Accueil des urgences, Montée du Dr Chapuis, 38209 Vienne, France
| | - Julien Berthiller
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon/University Claude Bernard Lyon 1 /HESPER EA 7425, Lyon, France
| | - Anne-Marie Schott
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon/University Claude Bernard Lyon 1 /HESPER EA 7425, Lyon, France
| | - Véronique Potinet
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d’Accueil des urgences, 165 chemin du Grand Revoyet, F-69495 Pierre Bénite, France
| | - Pierre Le Coz
- Aix-Marseille Université/EFS/CNRS, UMR 7268 ADéS, Faculté de Médecine, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Karim Tazarourte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d’Accueil des urgences, 5 place d’Arsonval, F-69003 Lyon, France
| | - Laurent Jacquin
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d’Accueil des urgences, 5 place d’Arsonval, F-69003 Lyon, France
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16
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Petri S, Zwißler B, in der Schmitten J, Feddersen B. Behandlung im Voraus Planen – Weiterentwicklung der Patientenverfügung. Anaesthesist 2019; 69:78-88. [DOI: 10.1007/s00101-019-00697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Loughlin M, Buetow S, Cournoyea M, Copeland SM, Chin-Yee B, Fulford KWM. [Not Available]. J Eval Clin Pract 2019; 25:911-920. [PMID: 31733025 DOI: 10.1111/jep.13297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022]
Abstract
There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as "ethical add-ons" but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that "sits within the minds" of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts.
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Affiliation(s)
- Michael Loughlin
- European Institute for Person-Centred Health and Social Care, University of West London, London, UK
| | - Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Michael Cournoyea
- Institute for the History and Philosophy of Science, University of Toronto, Toronto, Canada
| | - Samantha Marie Copeland
- Ethics and Philosophy of Technology Section, Department of Values, Technology and Innovation, Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
| | | | - K W M Fulford
- Collaborating Centre for Values Based Practice, University of Oxford, Oxford, UK
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